198320342-10-19-2024-11-AS-AINZ-DA7TQ6-20241019145524

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320342
Report Date: 10/19/2024
Date Signed: 10/19/2024 02:55:37 PM

Document Has Been Signed on 10/19/2024 02:55 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	OLIVE TREE HOME		FACILITY NUMBER:	198320342
ADMINISTRATOR/ DIRECTOR:	DUNGCA, ROMMEL		FACILITY TYPE:	740
ADDRESS:	1035 OLIVE AVE		TELEPHONE:	(562) 432-1163
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90813
CAPACITY: 18		CENSUS: 18	DATE:	10/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:42 PM
MET WITH:	Cezar Tuazon-Caregiver		TIME VISIT/ INSPECTION COMPLETED:	02:55 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 10/19/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Cezar Tuazon /Facility Staff. LPA explained the purpose of today’s visit. The facility is licensed to serve (18) elderly adults ages 60 and above, of which (18) can be non-ambulatory. The facility has an approved hospice waiver for (4).

The one-story residential home consists of ten (10) resident bedrooms, two (2) resident bathrooms, living room, dining room, family room, kitchen, office area, washer and dryer/ storage area, backyard with table and chairs.

LPA Iniguez and facility staff toured the physical plant. There were no bodies of water or obstructions on the premises. LPA inspected a total of (9) bedrooms and (2) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 113.5°F to 115.2°F, and the room temperature ranged from 76°F to 78°F.

The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2024

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

LIC809 (FAS) - (06/04)

Page: 1 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/19/2024

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
26
27
28
29
30
31
32

During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 7/15/24.

A review of (5) residents' service files and (3) staff personnel files was maintained in order. LPA reviewed (5) Medication Administration Records (MARs) and found no discrepancies.

LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance will be email to LPA. Facility Annual Fess current.

Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below:

-No facility staff available for approximately 30 minutes.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. *

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Cezar Tuazon / facility staff.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 10/19/2024 02:55 PM - It Cannot Be Edited

Created By: Alfonso Iniguez On 10/19/2024 at 02:40 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: OLIVE TREE HOME	FACILITY NUMBER: 198320342
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87413(a)(1)

Personnel - Operations

(1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview), the licensee did not comply with the section cited above in not having available staff for approximately 30 minutes which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/21/2024
	Plan of Correction
1 2 3 4	Licensee will ensure there are always available staff at all times. As plan of correction, licensee will re-train facility staff regarding staff avalaibility at the facility. Copy of trainining will sent to LPA via email before POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Eva M Alvarez

LICENSING EVALUATOR NAME:

Alfonso Iniguez

LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3