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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606902
Report Date: 05/22/2026
Date Signed: 05/22/2026 02:47:47 PM

Document Has Been Signed on 05/22/2026 02:47 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: 146CENSUS: 81DATE:
05/22/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Rolando Ongkiko - Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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On 5/22/2026, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan arrived at this facility to conduct a required Annual Inspection. Upon arrival LPA introduced herself by showing her department badge, was greeted by the Chief Executive Officer (CEO) Charles Arrieta and the Assistant Administrator (AA) Rolando Ongkiko. LPA explained the reason for the visit and requested staff and residents’ rosters for review.

LPA Khurshudyan reviewed the required postings on a wall and used the inspection tool to complete today's visit. The YES sign, Ombudsman information, Personal Rights, Disaster Plan, Master Menu, and Activity schedules are displayed along the hallway leading to the first-floor dining area.

A tour of the physical plant was conducted at around 10:50am and the following was noted:


The facility is fire cleared for one hundred forty-six (146) Non-ambulatory residents. The facility also has a hospice waiver for three (3) residents. The facility is currently occupying eighty-one (81) residents.
There is one main entrance being utilized at the facility. The facility is two-story building and has one (1) elevator. During the visit, LPA checked the elevator and observed it was operating properly.

The facility has a total of seventy-three (73) beds, of which forty-three are on the second floor and thirty (30) on the first floor. The facility has private and shared rooms for residents.

LPA observed several common bathrooms throughout the facility, all bathrooms appeared clean and were functional. Bathrooms had signs, grab bars and paper towels. The staff and resident bathrooms are not shared. Adjacent to the laundry room accessible from the facility is a shower area available for residents who cannot shower independently or require a larger space, such as those who use wheelchairs.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2026
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: 05/22/2026
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The kitchen is sufficiently stocked with at least two (02) days perishable and seven (07) days of non-perishable food. LPA observed a walk-in refrigerator and freezer stocked with adequate amount of frozen and fresh foods wrapped and stored appropriately. Food storage and preparation areas were clean and inaccessible to pests. Knives and sharps are observed on the counter-top, under supervision, and inaccessible to residents. A dietitian visits the facility every month. The daily menus were posted and available in the dining area. A restricted diet menu was also available for residents requiring special diets. The kitchen closes at 6:00pm and reopens at 6:00am.

The common areas and dining room appeared neat and clean. The activity room and TV room were nicely furnished. The monthly activity schedule was posted and available for residents. The facility also has library and a hair salon. All common areas were observed to be cleaned and properly furnished. The library has seating 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 facility maintains a comfortable temperature at 69°F-79°F.

The smoke and carbon monoxide detectors are hardwired, interconnected and centralized with automatic dispatch to the Los Angeles Fire Department. Last fire inspection was done on 4/27/2026. Fire extinguishers were located throughout the facility and observed to be fully charged and last inspected on 10/23/2025. LPA observed at least seven (7) fire extinguishers throughout the facility. There is also fire sprinklers located throughout the facility upstairs and downstairs.

LPA toured a random selection of resident rooms. All bedrooms were properly furnished and had appropriate bedding, linens and a lighting system. The call signal system was tested and functioned properly. Hallways were odorless and free of obstructions. Residents have enough personal hygiene products. The bathrooms were checked for cleanliness and proper operations. Towels and washcloths are not shared. There was enough clean linen available in each resident room. Hot water temperature measured between 107.3 and 117.2 degrees Fahrenheit.

There is a separate Medication Room on the first floor. LPA observed properly labeled medications and residents’ medical files to be locked and inaccessible to residents in care. The facility maintains a complete first aid kit. There are two (2) Med-techs / staff on duty during the daytime. Syringes for residents are stored in a red refrigerator, and residents self-administer their prescribed dosages. Diabetic and blood pressure readings are maintained in a binder, and the centrally stored medication destruction records are kept in a cabinet. Continue on LIC-809C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: 05/22/2026
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The facility has two (2) laundry rooms. The Laundry rooms observed to be locked. One laundry area is located outside and contains large washers and dryers, all cleaning supplies, chemicals and detergents are stored inside locked closets and inaccessible to residents. This area also stores extra linen. A second laundry area is located inside the facility and can be accessed with a key.

The facility has nice outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. All pathways are clear of obstruction.

Between 12:35pm -2pm LPA conducted records review of ten (10) staff files and eight

residents’ records. Files were complete and updated.

LPA collected LIC500, LIC9020, Copy of Administrator Certificate, and Copy of Liability Insurance.

No health and safety hazards noted during today’s visit.

No citations issued during today's visit.

Exit interview conducted. Copy of this report provided.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2026
LIC809 (FAS) - (06/04)
Page: 4 of 4