198320342-12-15-2022-11-AS-JCAN-CM5P4Z-20221215095957

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320342
Report Date: 12/15/2022
Date Signed: 12/15/2022 10:00:10 AM

Document Has Been Signed on 12/15/2022 10:00 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

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: 15	DATE:	12/15/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	ADMINISTRATOR ROMMEL DUNGCA		TIME COMPLETED:	10:15 AM

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 12/15/2022 around 09:00 AM Licensing Program Analysts (LPA) Jose Calderon conducted an announced visit for Olive Tree Home Facility and met face to face visit with Administrator Rommel Dungca for purpose of a pre-licensing evaluation. The requested capacity is for 18 non-ambulatory Adult Resident Facility. Facility is a 10 bedroom, 3 bathrooms, one-story house. The client bedrooms are spacious and will easily accommodate the client's furnishings. There is a backyard with a covered patio for shade. The patio contained 2 tables and 10 chairs. Outdoor passageways, walkways, driveways, steps and patios are free from obstructions. LPA Calderon did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. Residents Bedrooms: All 10 Bedrooms are for ambulatory/non-ambulatory clients. Bedroom’s #1 and #2 and #3 and #4, #5, #6, #7, #8, #9 and #10 has one bed each, one chair, one-night stand, one lamp, one dresser. Bathroom 3: Have a working toilet, wash basins, and walk-in shower, grab bars. LPA Calderon observed adequate lighting in hallway leading to bathrooms. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in hall closet. Emergency Phone Numbers, Exit Plan & Menu: The telephone system is a land line and operable. Emergency Disaster Plan and "See something, say something Let Us Know" was noted. Fire Extinguisher 1 mounted on the wall in hallway next to the kitchen.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: OLIVE TREE HOME	FACILITY NUMBER: 198320342
	VISIT DATE: 12/15/2022

NARRATIVE

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Food Service: Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked cabinet located in the kitchen area. Food supply is adequate; stored in kitchen refrigerator and cabinets and consists of the following: A variety of Fresh and Canned fruit, vegetable and meat food items. Emergency water supply was noted by LPA Calderon. Smoke Detectors: 11 hard wired smoke detectors are battery and electric. operated & working. Carbon monoxide 3 detector located and mounted in the hallway is operational. Appliances: Gas Stove, oven, microwave, washer, and dryer working. Refrigerator in the kitchen has a measured temperature of at least 37 degrees Fahrenheit for appropriate food storage. Freezer is at 0 zero degrees Fahrenheit. The residence is equipped with central air and heat and each client bedroom is individually climate controlled. Toxins: Locked/stored in the storage room located in the kitchen. Water Temperature: Bathrooms water temperature tested in #1 at 105 F. and #2 106 F. degrees, and #3 102 F degrees, Kitchen water temperature tested at 121 F degrees. Medications, First-Aid Kit & Book: Medication administration records storage area, and first aid kit has been inspected, which are stored in locked kitchen cabinet adjacent the refrigerator, available for staff use but inaccessible to clients.

Clients & Staff Files & Facility Records: Applicant will be handling cash resources of clients and surety bond Western Surety Company #66438486 for $2000.00 effective 10/26/2022. LPA Calderon noted the Administrator Rommel G Dungca Certification # 6001081740 expiration date of 07/08/2023. LIC308 Designation of Facility Responsibility for Jucarcris Castro dated 11/18/2022. General Lability Policy #0100191726-0 policy period from 05/23/2022 to 05/23/2023 underwritten by Kinsale Insurance Company, coverage 100,000/300,000. Records of staff and clients shall be stored in a locked in staff closet and the section has been inspected.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: OLIVE TREE HOME	FACILITY NUMBER: 198320342
	VISIT DATE: 12/15/2022

NARRATIVE

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Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the client's use. LPA Calderon did not observe any pet or bodies of water at the facility. LPA Calderon did not observe delayed egress, chain locks or dead bolts on exits. LPA Calderon did not observe pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency on side gates and front exits. Pool/Jacuzzi & Pets: LPA Calderon did not observe any pet or bodies of water at the facility. Fire clearance: Fire Clearance #283200 was approved on 11/09/2022 for 18 ambulatory clients with no special instructions by Long Beach Fire Department. LPA Calderon did not observe delayed egress, chain locks or dead bolts on exits. LPA Calderon did not observe pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency on side gates and front exits.

Component III: (07/15/2022) about how to operate the facility within substantial compliance was reviewed with licensee Rommel Dungca.

An exit interview was conducted with Administrator Rommel Dungca, and a copy of this report has been furnished to the applicant by hand. Accordingly, LPA Jose Calderon will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022

LIC809 (FAS) - (06/04)

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