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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197606902
Report Date:
08/17/2022
Date Signed:
08/17/2022 11:17:20 AM
Document Has Been Signed on
08/17/2022 11:17 AM
- 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:
78
DATE:
08/17/2022
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME BEGAN:
09:50 AM
MET WITH:
Charles Arrieta
TIME COMPLETED:
11:20 AM
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On 08/17/22 Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to conducted an unannounced Case Management Incident visit. Upon arrival LPA met with administrator Charles Arrieta and the purpose of the visit was explained. The purpose of the visit it to obtain more information regarding the documents previously emailed to LPA.
On 07/13/22 Community Care Licensing received an incident report of a missing resident. R1 was found to be missing on 07/12/22 during night time medication rounds. Facility contacted Los Angles Police Department to report missing resident. LPA requested R1's Physician's Report (LIC 602) and R1's Preplacement Appraisal Information (LIC 603). LPA contacted R1's physician and was informed that more detail information will be provided around 1:00 p.m today. LPA could not wait at the facility until this time to obtained final information. LPA will communicate with R1's physician and will conduct a subsequent visit once information is obtained.
Exit interview conducted. Report signed and delivered.
SUPERVISOR'S NAME:
Nichelle Gillyard
TELEPHONE:
(818) 596-4341
LICENSING EVALUATOR NAME:
Joscelyn Martinez
TELEPHONE:
(818) 383-6108
LICENSING EVALUATOR SIGNATURE:
DATE:
08/17/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/17/2022
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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