198600454-6-25-2025-11-AS-EMAZ-DKRU53-20250821151559

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600454
Report Date: 06/25/2025
Date Signed: 06/25/2025 10:24:57 AM

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
04/16/2025 and conducted by Evaluator Alfonso Iniguez

COMPLAINT CONTROL NUMBER: 11-AS-20250416161600

FACILITY NAME:	OLIVE'S HOME		FACILITY NUMBER:	198600454
ADMINISTRATOR:	JAIME DURAN		FACILITY TYPE:	735
ADDRESS:	20020 BROADACRES AVENUE		TELEPHONE:	(310) 604-6010
CITY:	CARSON	STATE: CA	ZIP CODE:	90746
CAPACITY:	6	CENSUS: 4	DATE:	06/25/2025
		UNANNOUNCED	TIME BEGAN:	09:33 AM
MET WITH:	Rizalie Bondoc/DSP		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Resident sustained an unexplained injury while in care.

INVESTIGATION FINDINGS:

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On 6/25/25, at approximately 9:30 AM, Licensing Program Analyst-LPA Alfonso Iniguez conducted a subsequent unannounced complaint visit. LPA Iniguez met with Rizalie Bondoc/DSP. LPA explained the purpose of this visit.

Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), Client’s interviews (C#2-C#4), Staff Interview (S#1) and Witnesses interviews (W#1 and W#2). LPA obtained and reviewed the following documents: Client’s roster, Personnel roster, copies of (C#1)’s latest Individual Program Plan (IPP) from South Central Los Angeles Regional Center (SCLARC) dated: 01/10/24, Copies of (C#1)’s hospitalization discharge papers dated:4/21/25 and Copies of facility staff training regarding Client’s Rights dated:5/14/25.

Evaluation Report continues LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2025

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-20250416161600

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'S HOME	FACILITY NUMBER: 198600454
	VISIT DATE: 06/25/2025

NARRATIVE

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Investigation Revealed the Following:

Allegation: Allegation: Resident sustained an unexplained injury while in care.

The details of the complaint alleged that (C#1) sustained unexplained injuries while in care.

On June 25, 2025, at approximately 10:00 AM, LPA Iniguez reviewed records and observed the hospitalization discharge papers for (C#1), dated April 21, 2025. LPA Iniguez noted that there were no indications of injuries sustained by (C#1) due to staff negligence. Additionally, LPA Iniguez examined (C#1)’s most recent Individual Program Plan (IPP) from the South-Central Los Angeles Regional Center (SCLARC), dated January 10, 2024. There were no notes from the Regional Center Service Coordinator (SC) suggesting that the facility was neglectful in the care of (C#1). Moreover, LPA Iniguez observed Copies of facility staff training regarding Client’s Rights dated:5/14/25.

On April 22, 2025, at approximately 2:00 PM, during an interview with the Administrator (A#1), he stated that he is aware of the client’s rights and (C#1) did not sustain unexplained injuries due to facility staff negligence. In addition, (A#1) stated that the facility staff are always assisting (C#1) and all the clients in the care.

On April 22, 2025, at approximately 2:30 PM, during an interview with Witnesses 1 and 2 (W#1-W#2), (2) out of (2) stated that during their visits to (C#1), they had never observed negligence from facility staff. In addition, (2) out of (2) Witnesses stated that they have no complaints regarding (C#1)’s care at the facility.

On June 25, 2025, at approximately 9:30 AM, the Licensing Program Analyst-LPA was unable to speak with (C#1) because they were at a Skilled Nursing Facility (SNF) in the city of Norwalk following their hospitalization in April.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2025

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20250416161600

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'S HOME	FACILITY NUMBER: 198600454
	VISIT DATE: 06/25/2025

NARRATIVE

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On April 22, 2025, at approximately 3:00 PM, during interviews with Clients (C#2-C#4), (3) out of (3) stated that they think the facility staff is adequately trained on how to take care of them. Also, (3) out of (3) clients in care stated that they have never sustained injuries due to the negligence of the facility staff.

On April 22, 2025, at approximately 3:30 PM, during interviews with Facility Staff (S#1-S#2), (2) out of (2) stated that they are aware of clients rights and they also stated that (C#1) did not sustained injuries due to their negligence.

During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegation(s).

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED.

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.

An exit interview was conducted, and a copy of the Complaint Report was given to Rizalie Bondoc/DSP.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2025

LIC9099 (FAS) - (06/04)

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