198320342-2-21-2025-11-AS-JHAD-DEEPS6-20250303103350

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320342
Report Date: 02/21/2025
Date Signed: 02/21/2025 01:46:26 PM

Unsubstantiated

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
02/14/2025 and conducted by Evaluator Perry Scott

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20250214082212

FACILITY NAME:	OLIVE TREE HOME		FACILITY NUMBER:	198320342
ADMINISTRATOR:	DUNGCA, ROMMEL		FACILITY TYPE:	740
ADDRESS:	1035 OLIVE AVE		TELEPHONE:	(562) 432-1163
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90813
CAPACITY:	18	CENSUS: 16	DATE:	02/21/2025
		UNANNOUNCED	TIME BEGAN:	09:38 AM
MET WITH:	Cezar Tuazon		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Due to lack of supervision, resident physically assaults other residents.

INVESTIGATION FINDINGS:

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On 2/21/25, at 9:30am, Community Care Licensing Division (CCLD) Staff conducted an initial complaint visit to the facility and was greeted by Cezar Tuazon, Direct Care Staff. CCLD explained the purpose of this visit is to gather information about the complaint, interview staff and residents, and deliver findings for the allegation mentioned above.

The investigation consisted of the following: An initial complaint visit was completed by (CCLD) staff on 2/21/2025. The department investigated the allegation mentioned in this complaint; and conducted interviews with staff (S1-S2) and residents (R1-R7). Staff Roster (Dated: 10/30/24), Resident Roster (Dated: 10/30/24), ID/Emergency Information (Dated: No Date), and Face Sheet (Dated: No Date) were obtained from the facility.

The investigation revealed the following: Allegation- Due to lack of supervision, resident physically assaults other residents.

Complaint Investigation Report On LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20250214082212

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: 02/21/2025

NARRATIVE

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The details of the complaint alleged that the facility does not provide adequate supervision of the residents. It is alleged that resident (R1) assaulted resident (R2) at the facility with their walker. On 02/21/25, from 9:30am-1:30pm, the department interviewed staff (S1-S2) and residents (R1-R7) regarding the allegation. 2 of 2 staff denied the allegation that Due to lack of supervision, resident physically assaults other residents. All staff (S1-S2) interviewed stated that the facility does have enough staff to supervise the residents in the facility. All staff (S1-S2) denied the allegation that residents are assaulting each other. Staff stated that there was an incident where a resident was praying with their hands to the sky and another resident tried to put their hands down. Staff stated that the resident was not aware of what the other resident was doing and did not know that they were praying. Staff stated that they explained what the resident was doing and not to try and put the residents’ hands down because it was not right to do so. Staff stated that the resident apologized, and it was okay between them after that. But that the resident did not assault or hit the other resident at any time. Staff also stated that they did not witness resident (R1) hit resident (R2) with their walker.

The department interviewed residents (R1-R7) about the allegation and 7 of 7 residents that were interviewed denied the allegation that Due to lack of supervision, resident physically assaults other residents. All residents that were interviewed (7 of 7) stated that they have never been assaulted by any resident at the facility and there is enough staff to supervise the residents in the facility. The department interviewed R1 and R2 about any alleged altercation between the two and both denied any knowledge of an altercation and R1 denied that R1 hit R2 with their walker. R2 also denied that R1 hit R2 with their walker.

The department reviewed the Staff Roster (Dated: 10/30/24) and observed that there is enough staff on the day and night shift to supervise the residents properly.

Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegation that Due to lack of supervision, resident physically assaults other residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

No citations were issued on this complaint visit.

An exit interview was conducted, and a hard copy of this Complaint Investigation Report was provided to Cezar Tuazon, Direct Care Staff.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

LIC9099 (FAS) - (06/04)

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