<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606902
Report Date: 05/26/2022
Date Signed: 05/26/2022 01:28:31 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/20/2022 and conducted by Evaluator Joscelyn Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20220520161838
FACILITY NAME:OLIVE BRANCH ASSISTED LIVING, THEFACILITY NUMBER:
197606902
ADMINISTRATOR:CHARLES ARRIETAFACILITY TYPE:
740
ADDRESS:10215 BALBOA BLVD.TELEPHONE:
(818) 368-8581
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY:146CENSUS: 79DATE:
05/26/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Charles Arrieta TIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not safeguard resident's personal belongings
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 05/26/22 Licensing Program Analysts (LPAs) Joscelyn Martinez and Melissa Ruiz arrived at the facility to conduct an unannounced complaint visit. Upon arrival LPAs me with Administrator Charles Arrieta and the purpose of the visit was explained.

At 10:30 a.m LPAs conducted interviews with eight residents and three staff member.

Staff did not safeguard resident's personal belongings

It is alleged that staff are not safeguarding residents’ belongings and are being misplaced or missing. Interview with S1 revealed that R1 did inform S1 that they had personal belongings missing or lost. The personal belongings in question are clothing but more importantly, two pillows designed for neck support needed for a medical condition. The interview additionally revealed that once R1 informed S1 about these missing items, no LIC 9060, Resident Theft and Lost Record, was filled out.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 31-AS-20220520161838
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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
VISIT DATE: 05/26/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on record reviews conducted at 12:25 p.m, LPAs did not observe a LIC 9060 on file. Based on the information obtained, this allegation is deemed Substantiated at this time.

Deficiency issued. See 809-D

Exit interview conducted. Report signed and delivered. Appeal rights delivered.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20220520161838
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
06/02/2022
Section Cited
CCR
87218(a)(2)
1
2
3
4
5
6
7
87218(a)(2) Theft and Loss A licensee who fails to make reasonable efforts to safeguard resident property, shall reimburse a resident for or replace stolen or lost resident property at its current value. The licensee shall be presumed to have made reasonable efforts to safeguard resident property...
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator and staff will complete in house training on Theft and Loss program for the facility and how to properly fill a LIC 9060. Two pillows will be replaced for R1 of equal value and needs. Proof of training and receipt of pillow purchase should be emailed to LPA no later than 06/02/22.
8
9
10
11
12
13
14
Based on record review and interview, administrator did not ensure in safeguarding resident’s personal belongings by failing to fill out a LIC 9060 once R1 stated their personal belongings were missing or lost. This posses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/20/2022 and conducted by Evaluator Joscelyn Martinez
COMPLAINT CONTROL NUMBER: 31-AS-20220520161838

FACILITY NAME:OLIVE BRANCH ASSISTED LIVING, THEFACILITY NUMBER:
197606902
ADMINISTRATOR:CHARLES ARRIETAFACILITY TYPE:
740
ADDRESS:10215 BALBOA BLVD.TELEPHONE:
(818) 368-8581
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY:146CENSUS: DATE:
05/26/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:TIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff withheld resident's mail
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 05/26/22 Licensing Program Analysts (LPAs) Joscelyn Martinez and Melissa Ruiz arrived at the facility to conduct an unannounced complaint visit. Upon arrival LPAs me with Administrator Charles Arrieta and the purpose of the visit was explained.

At 10:30 a.m LPAs conducted interviews with eight residents and three staff member.

Staff withheld resident's mail
It is alleged that a staff member withheld residents mail for a period of time. Interview with staff member revealed that on 05/11/22 USPS dropped a larger amount of mail for R1. This is the only occasion that R1 has received a larger quantity of mail. The mail received for R1 was correspondence from January 2022 to May 2022 and is an isolated incident. Interviews with seven (7) out of eight (8) residents stated they have not experienced any issues with staff member withholding their mail. Based on interviews obtained, there is not sufficient evidence to determined staff member withheld residents mail. This allegation is deemed Unsubstantiated at this time.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (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.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20220520161838
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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
VISIT DATE: 05/26/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on interviews obtained, there is not sufficient evidence to determined staff member withheld residents mail. This allegation is deemed Unsubstantiated at this time.

Exit interview conducted. Report signed and delivered.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 5 of 5