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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606902
Report Date: 05/20/2025
Date Signed: 05/20/2025 02:52:56 PM

Document Has Been Signed on 05/20/2025 02:52 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:OLIVE BRANCH ASSISTED LIVING, THEFACILITY NUMBER:
197606902
ADMINISTRATOR/
DIRECTOR:		CHARLES ARRIETAFACILITY TYPE:
740
ADDRESS:10215 BALBOA BLVD.TELEPHONE:
(818) 368-8581
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 146TOTAL ENROLLED CHILDREN: 0CENSUS: 82DATE:
05/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:CHARLES ARRIETA, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:05 PM
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On 05/20/25 at 9:20 AM, Licensing Program Analyst (LPA) Gina Saucedo, arrived to conduct an unannounced, annual inspection at the facility. Upon arrival, LPA Saucedo met with Administrator, Charles Arrieta and disclosed the purpose of the visit.

LPA asked for the census, resident, and staff files. A physical tour was conducted at 10:30AM and observed the following:



The entire facility has at total of 73(seventy-three) beds. Forty-three (43) on the second floor and thirty (30) on the first floor. The physical tour started on the first floor. Random Bedrooms were randomly selected to tour and were observed to have appropriate furniture, lightening, bedding and televisions. Some of the bedrooms had their own small refrigerators, utensils. Random Bathrooms were observed to have grab bars and non-skid mats. Hot water temperature was tested randomly for and measured 118–119-degree Fahrenheit.

Fire extinguishers were observed throughout the facility and were fully charged on green with different dates such as October 2025 and May 2025. There are fire extinguishers upstairs, downstairs and in the kitchen area. Carbon Monoxide and fire alarms are located throughout the facility and are operable. There are also fire sprinklers located throughout the facility upstairs and downstairs.

809C-continued
Troy AgardTELEPHONE: (818) 596-4334
Gina SaucedoTELEPHONE: (818) 304-3057
DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/20/2025
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Facility has a designated medication room that is inaccessible to residents where all the medication is stored and locked. There are two (2) medical-technician staff during the daytime. The syringes for residents are kept in a refrigerator and the residents are provided with the dosage but they administer it themselves. The diabetic and high blood pressure results are kept in a binder. The centrally stored medication destruction record is sheet is kept in a cabinet.

The outside/backyard/patio area was accessible to residents with different areas for them to sit. There is appropriate outdoor furniture for the residents to sit on with proper shading. There is no body of water.

Common Areas: These include the dining areas, library, hair salon, and activities room. All common areas were observed to be cleaned and properly furnished. The library has sitting for residents and has books in several shelves on the second floor. The activity room has a large television and has enough seating for several residents to watch the television and do different activities on the second floor. The dining area has the menu against the wall. Facility maintains a comfortable temperature of 75, 76, 80, 81-degree Fahrenheit. There are several temperature thermostats throughout the facility.

There are several common bathrooms throughout the upstairs and downstairs area. The staff and resident bathrooms are not shared. There are several separate bathrooms for residents and staff throughout the facility. There are trash cans with lids and covid signs posted in the common bathrooms. There is toilet paper and napkins. There is one (1) egress chair located in the facility office.

There are two (2) facility laundry areas. One (1) is located outside and has large washers and dryers with locked chemicals inaccessible to the residents. This laundry area has extra linen, and one (1) is located inside that can be entered from the facility with a key. Next to the laundry room that is accessible from the facility is a shower area that residents can use if they cannot shower themselves or need a larger area to shower for example residents with wheelchairs.

809C-continued
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina SaucedoTELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/20/2025
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The Kitchen area was toured, and LPA observed there to be sufficient seven (7) day supply of non-perishable foods and perishable food for all residents. The kitchen area was clean at the time of the tour. The dining area is located next to the kitchen where different residents were having lunch with proper feeding utensils/plates/cups. Next to the kitchen/dining room area is a vending machine for residents and staff use that has snacks. There is fire extinguisher and fire sprinklers in the kitchen area.

Administrative: The Insurance plan is dated as of 09/07/2025. There is a disaster plan manual located in the office of the facility where the staff and resident files are located. The last disaster and fire drill was conducted on 4/28/25, 03/22/25, 02/23/25 and 01/25/25. There is a company that is named SouthWest contracted by the facility to do fire drills. The YES sign, Ombudsman, Personal Rights, Disaster Plan, Master Menu and Activities are located down the hallway leading to the dining area on the first floor

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

SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina SaucedoTELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025
LIC809 (FAS) - (06/04)
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