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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197606902
Report Date:
05/26/2022
Date Signed:
05/26/2022 01:25:53 PM
Document Has Been Signed on
05/26/2022 01:25 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
21731 VENTURA BLVD., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
OLIVE BRANCH ASSISTED LIVING, THE
FACILITY NUMBER:
197606902
ADMINISTRATOR:
CHARLES ARRIETA
FACILITY TYPE:
740
ADDRESS:
10215 BALBOA BLVD.
TELEPHONE:
(818) 368-8581
CITY:
NORTHRIDGE
STATE:
CA
ZIP CODE:
91325
CAPACITY:
146
CENSUS:
79
DATE:
05/26/2022
TYPE OF VISIT:
POC
UNANNOUNCED
TIME BEGAN:
09:30 AM
MET WITH:
Charles Arrieta
TIME COMPLETED:
10:30 AM
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On 05/26/22 Licensing Program Analysts (LPAs) Joscelyn Martinez and Melissa Ruiz conducted an unannounced Plan of Correction (POC) visit.
On 05/18/22 LPA Joscelyn Martinez conducted an unannounced annual visit. During this visit facility was cited under Regulation
87470(c)(1)(f). During today's visit LPAs observed designated staff Densie Ortiz in the lobby taking temperature of visitors. LPAs' temperature was taken and asked to sign in.
POC was cleared on today's visit.
Exit interview conducted. Report signed and delivered. POC clearance letter delivered.
SUPERVISOR'S NAME:
Nichelle Gillyard
TELEPHONE:
(818) 596-4341
LICENSING EVALUATOR NAME:
Joscelyn Martinez
TELEPHONE:
(818) 383-6108
LICENSING EVALUATOR SIGNATURE:
DATE:
05/26/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
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