197606902-1-21-2025-31-AS-TAGD-DDSTZH-20250211141023

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606902
Report Date: 01/21/2025
Date Signed: 01/21/2025 02:43:29 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/16/2025 and conducted by Evaluator Gina Saucedo

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20250116163655

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: 85	DATE:	01/21/2025
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Charles Arrieta		TIME COMPLETED:	02:55 PM

ALLEGATION(S):

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Facility is unlawfully evicting resident

INVESTIGATION FINDINGS:

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On 01/21/25, at 9:40am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Administrator Charles Arrieta. LPA explained the purpose of this visit was to gather information, interview staff and residents and deliver findings for this complaint.

On 01/21/25, LPA Saucedo asked for the census, staff, and resident rosters. On 01/21/25, LPA Saucedo conducted a physical tour and interviewed staff and residents.

LIC 9099C-continued

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20250116163655

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: OLIVE BRANCH ASSISTED LIVING, THE	FACILITY NUMBER: 197606902
	VISIT DATE: 01/21/2025

NARRATIVE

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Regarding the allegation: Facility is unlawfully evicting resident. It is being alleged that resident #1 (R1) has refused to take prescribed medication and has endangered himself and others. A thirty (30) day eviction notice was provided to the resident on 01/13/25 and was sent to CCLD-Community Care Licensing Department on 01/14/25. On 01/13/25, R1 became aggressive with their roommate and a staff member, 911 and R1’s Veteran Affair’s Case Manager were called. R1 was then taken to the hospital and placed on a 51/50 hold. On 12/16/24, CCLD received an Unusual/Incident/Injury Report regarding R1 coming into the staff office and becoming aggressive with the business manager by pulling the facility resident financial records book from their hands. On 12/17/24, R1 received a final warning regarding their aggressive behavior; and thus, house rules being violated. The resident appraisal was updated on 12/25/24 regarding R1. Seven (7) out eight (8) residents confirmed that they have not had an unlawful eviction notice given to them. During resident interviews, two (2) residents confirmed that R1 was aggressive with them. Four (4) staff confirmed that R1 was aggressive with them. LPA obtained R1’s Admission Agreement which states verbal, or physical abuse directed towards other residents or staff is grounds for eviction and harming or threatening to harm oneself and others. Therefore, based on the LPA's records review, staff and resident interviews, the above allegation(s) above is UNSUBSTANTIATED at this time.

An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Administrator.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025

LIC9099 (FAS) - (06/04)

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