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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320342
Report Date: 06/24/2024
Date Signed: 06/24/2024 11:08:38 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/19/2024 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240619112759
FACILITY NAME:OLIVE TREE HOMEFACILITY NUMBER:
198320342
ADMINISTRATOR:DUNGCA, ROMMELFACILITY TYPE:
740
ADDRESS:1035 OLIVE AVETELEPHONE:
(562) 432-1163
CITY:LONG BEACHSTATE: CAZIP CODE:
90813
CAPACITY:18CENSUS: 16DATE:
06/24/2024
UNANNOUNCEDTIME BEGAN:
08:31 AM
MET WITH:Cezar Tuazon, Direct Support Professional (DSP)TIME COMPLETED:
12:02 PM
ALLEGATION(S):
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Staff are not properly addressing bed bug infestation in facility
INVESTIGATION FINDINGS:
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On 06/24/2024 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the above-mentioned facility. LPA was met by Cezar Tuazon, Direct Support Professional (DSP) (S1) and the purpose of the visit was explained. S1 and LPA toured the facility.

The investigation consisted of the following:
On 06/24/2024 LPA requested and reviewed facility documents and toured the facility. LPA interviewed two (2) out of sixteen (16) residents and one (1) out of three (3) staff.

The investigation revealed the following:
Regarding the allegation: "Staff are not properly addressing bed bug infestation in facility.". It has been alleged that one resident had been observed to have bed bugs on their body.
Between 09:00AM and 10:30AM, on 06/24/2024, LPA observed one (1) bed bug exoskeleton and one (1) live bed bug in a resident's bed in the resident's room (room six). Report continues, see LIC9099C
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024
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 3
Control Number 11-AS-20240619112759
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: OLIVE TREE HOME
FACILITY NUMBER: 198320342
VISIT DATE: 06/24/2024
NARRATIVE
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Interviews revealed that 1 out of 1 staff and 1 out of two (2) residents have agreed with the allegation.
Record reviews revealed that the last pest control visit was conducted on 06/25/2022.

Based on LPA's observations, record reviews and interviews conducted, the preponderance of evidence standard has been met.
Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC 9099D.

An exit interview was held with Cezar Tuazon, DSP, and a copy of appeal rights and this report has been provided.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20240619112759
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: OLIVE TREE HOME
FACILITY NUMBER: 198320342
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/28/2024
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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The licensee has agreed to update the house rules, to include "Residents shall not bring in any outside items, which includes clothing that has not been sanitzed at 120 degrees F or above."
In addition, licensee has agreed to contact a commercial exterminator and follow the
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The licensee did not comply with the section cited above in staff knowing there were bed bugs which were not dealt with through a commercial pest exterminator. This poses a potential Health, Safety or Personal rights risk to residents in care.
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guidance provided by this commercial exterminator to prevent any future occurance of infestation at the facility. Licensee will send a copy of the updated facilities' house rules and all exterminator visits and recommendation provided by exterminator to LPA at MARIO.LEON@DSS.CA.GOV
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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.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3