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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320342
Report Date: 08/18/2025
Date Signed: 08/18/2025 03:28:10 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
08/13/2025 and conducted by Evaluator Felisa Shirley
COMPLAINT CONTROL NUMBER: 11-AS-20250813135605
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: 17DATE:
08/18/2025
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Rommel Dungca, AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility staff are not safeguarding resident belongings.
Facility staff did not ensure to provide a safe environment for residents in care.
INVESTIGATION FINDINGS:
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On 8/18/25 Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA Shirley arrived and spoke to staff, Romina Ocampo and the purpose of the visit was discussed. LPA was granted access to the facility.

The investigation consisted of the following:

On 8/18/25 LPA requested and reviewed copies of the following records: Resident file, Resident Roster, LIC 500, Resident Face Sheet, Admission Agreement, Physician’s Report, Client/Resident Personal Property and Valuables list (LIC 621), Weekly Laundry Schedule, Unusual Incident/Injury report. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff-4. Resident 1 – Resident 5.

The investigation revealed the following:
Con'd on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2025
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-20250813135605
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: 08/18/2025
NARRATIVE
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Allegation: Facility staff are not safeguarding resident belongings.

It is alleged that R-1 was missing a pair of jeans and a hat was stolen. During interviews, on 8/18/25 LPA Felisa Shirley ask S-1 if this facility had a lost and found and was told no it does not. LPA Shirley reviewed R-1’s facility file. Per resident’s admission agreement, R-1 has been a resident at the above named facility since 1/2/24. LPA Shirley reviewed R-1’s Client/Resident Personal Property and Valuables (LIC 621) list. On the list, “Wish Not to List” was written in the description section and the form was signed by R-1 on 1/2/24. LPA Shirley toured the facility went to the laundry room in search of R-1’s missing items and did not observe any misplaced jeans. LPA Shirley went to R-1’s room and conducted a search of said missing items. LPA Shirley observed that there were 2 pairs of jeans hanging in the closet, a folded pair of jeans in R-1’s drawer and on 8/18/25, R-1 was wearing a pair of jeans. LPA observed 4 baseball caps in one drawer and 1 black leather hat underneath some clothes in another drawer.

LPA interviewed staff 1 – staff 4 (S-1 – S-4). Of those interviewed 4 out of 4 denied the allegation. LPA interviewed Resident 1 – Resident 5(R-1 – R-5). Of those interviewed 5 out of 5 denied the allegation.

Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.

Allegation: Facility staff did not ensure to provide a safe environment for residents in care.

It is alleged that R-1 initiated an alteration due to the theft of R-1’s belongings. All residents that were interviewed, 5 out of 5 stated that they have never had a physical altercation with any of the residents. LPA Shirley reviewed the facilities incident reports for 2025 and observed that R-1 was the sole aggressor in the reported altercations against other residents. Per interview with S-1, in all situations staff is always on stand by to assist when needed to all residents in care. Per LPA observation, there is an appropriate staff to resident ratio noting that the facility does have enough staff to supervise the residents in this facility.

Con'd on 9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20250813135605
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: 08/18/2025
NARRATIVE
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LPA interviewed staff 1 – staff 4 (S-1 – S-4). Of those interviewed 4 out of 4 denied the allegation. LPA interviewed Resident 1 – Resident 5(R-1 – R-5). Of those interviewed 4 out of 5 denied the allegation. One resident confirmed the allegation.

Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.

No deficiencies were cited for these allegations.

An exit interview was conducted and a copy of this report was provided to staff, Romina Ocampo.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3