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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600454
Report Date: 07/16/2025
Date Signed: 07/16/2025 03:35:49 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
04/16/2025 and conducted by Evaluator Alfonso Iniguez
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250416161600
FACILITY NAME:OLIVE'S HOMEFACILITY NUMBER:
198600454
ADMINISTRATOR:JAIME DURANFACILITY TYPE:
735
ADDRESS:20020 BROADACRES AVENUETELEPHONE:
(310) 604-6010
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY:6CENSUS: 4DATE:
07/16/2025
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Rizalie Bondoc/DSPTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident sustained an unexplained injury while in care.
INVESTIGATION FINDINGS:
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On 7/16/25, at approximately 2:30 PM, 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, and a copy of staff training regarding the importance of observing client’s seizures.

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: 07/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2025
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-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: 07/16/2025
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 received an email from a hospital social worker. In the email, they stated that no notes indicate (C#1) signs of neglect. Moreover, LPA Iniguez observed Copies of facility staff training regarding clients' rights, dated May 14, 2025, and a copy of staff training regarding the importance of observing clients' seizures. The training indicates that facility staff will record clients' seizure episodes, including their duration and techniques used to prevent injury during these events.

On April 22, 2025, at approximately 2:00 PM, during an interview with the Administrator (A#1), he states that on the morning of April 21, 2025, (C#1) looked disoriented and not themselves, also, (C#1) did not have signs of injuries on them. (A#1) called we informed (C#1) 's placement agency, their physician, and (C#1) 's representatives. (C#1) was admitted, and the hospital test result showed (C#1) sustained a Traumatic Brain Injury (TBI). (A#1) stated that neither he nor the facility staff observed (C#1) sustaining a fall or having a seizure that might cause their injury.

On April 22, 2025, at approximately 2:30 PM, during an interview with Witnesses 1 (W#1), they stated that the placement agency is currently conducting its investigation. Additionally, (W#1) stated that during the visits conducted at the facility, they observed facility staff being attentive towards (C#1) and the other clients in care. Additionally, (W#1) stated that during their visits to the facility, they have never witnessed neglect towards.
Evaluation Report continues LIC 9099-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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: 07/16/2025
NARRATIVE
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On April 22, 2025, at approximately 2:30 PM, during an interview with Witness 2 (W#2), they stated that they visit the facility every week. They observed that the staff is properly tending to (C#1)’s needs and noted that there are no signs of neglect or lack of supervision.

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.

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 did not witness (C#1) sustaining a fall or have an event, and 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 the client’s rights, and they also indicated that they did not witness (C#1) sustaining a fall or having an event. Also, (2) out of (2) facility staff stated that (C#1) did not sustain 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: 07/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3