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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606902
Report Date: 07/25/2023
Date Signed: 07/25/2023 04:19:13 PM


Document Has Been Signed on 07/25/2023 04:19 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



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:
07/25/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Rolando OngkikoTIME COMPLETED:
02:40 PM
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On 7/25/2023 Licensing Program Analyst (LPA) Melissa Spaeth, initiated a complaint investigation for Complaint #31-AS-20230719132921. During LPA’s tour of the facility, LPA observed a small hole with a water mark in the ceiling of a resident's room.

At 1:45 pm, LPA and the Assistant Administrator observed the damaged ceiling. The Assistant Administrator stated the maintenance staff observed the water mark in the ceiling and had begun the repair work; however, the repair work had not been completed. At 2:00 pm, the Administrator stated there were water leaks in the facility due to heavy rains that occurred a few months ago. The repair work had been an ongoing process. LPA Spaeth stated the damaged ceiling in the resident's room will need to be repaired.

Based upon LPA's observations, and pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency was cited (refer to LIC 809-D).

Exit interview conducted, Appeal Rights discussed, and a copy of the report was issued to Administrator.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2023
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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Document Has Been Signed on 07/25/2023 04:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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: 07/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/01/2023
Section Cited
CCR
87303(a)

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87303 Maintenanc & Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services.. for the safety and well-being of residents, … This was evidenced by:
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Administrator stated will request maintenance staff members to repair the damaged ceiling.
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LPA observed a damaged ceiling in a resident's room which has not been repaired and poses an immediate health, safety or personal rights risk to person in care.
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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: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2023
LIC809 (FAS) - (06/04)
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