197606902-1-13-2024-31-AS-GSAO-CZFVAF-20240113151549

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606902
Report Date: 01/13/2024
Date Signed: 01/13/2024 03:16:26 PM

Document Has Been Signed on 01/13/2024 03:16 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, 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: 83	DATE:	01/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Rolly Ongkiko		TIME COMPLETED:	03:15 PM

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	On 01/13/24 at 09:35 AM, Licensing Program Analyst (LPA) Gina Saucedo, arrived to conduct an unannounced, annual inspection at the facility. Upon arrival, LPA Saucedo met with MedTech, Yolanda Lopez and disclosed the purpose of the visit. The Assistant Administrator was called and arrived at 11:25 AM Rolly Ongkiko. LPA asked for the census, resident, and staff rosters. A physical tour was conducted at 11:45 AM 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 second 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. Random Bathrooms were observed to have grab bars and non-skid mats. Hot water temperature was tested randomly for and measured 112–118-degree Fahrenheit. Fire extinguishers were observed throughout the facility and were fully charged on green with different dates. There are fire extinguishers upstairs, downstairs and in the kitchen area. Carbon Monoxide and fire alarms are located throughout the facility and are operable. Facility has a designated medication room that is inaccessible to residents where all the medication is stored and locked. There are always two (2) med-tech staff in there during the daytime. The outside/backyard is 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. 809C-continued

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2024

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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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: 01/13/2024

NARRATIVE

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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. The activity room has a large television and has enough seating for several residents to watch the television and do different activities. Facility maintains a comfortable temperature of 72.-76-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 trash cans with lids and covid signs posted in the common bathrooms. There is toilet paper and napkins.

There are two facility laundry areas. One is located outside and has large washers and dryers with locked chemicals inaccessible to the residents. This laundry area has extra linen, and one 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.

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.

Administrative: There is no annual fee that is due right now. The Insurance plan is dated as of 09/12/23. There is a disaster plan manual located in the office of the facility where the staff and resident files are located. The last fire drill conducted was on 12-12-2023.

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

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2024

LIC809 (FAS) - (06/04)

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