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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600454
Report Date: 12/12/2024
Date Signed: 12/12/2024 12:01:29 PM

Document Has Been Signed on 12/12/2024 12:01 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'S HOMEFACILITY NUMBER:
198600454
ADMINISTRATOR/
DIRECTOR:		HARRIS, JOFACILITY TYPE:
735
ADDRESS:20020 BROADACRES AVENUETELEPHONE:
(310) 604-6010
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 6CENSUS: 4DATE:
12/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:44 AM
MET WITH:Rizalie BondocTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On 12/12/24, at 9:40am, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced visit to Olive’s Home. The purpose of today’s visit was to conduct the required annual inspection, using the new Care Tool. LPA was met by Rizalie Bondoc, Direct Support Staff (DSP), and the purpose of today’s visit was explained. The facility is licensed to serve four (4) ambulatory Developmentally Disabled Clients (age 18-59) of which two (2) may be non-ambulatory. Currently, the home has (3) ambulatories and one (1) non-ambulatory client. The clients are South Central Los Angeles Regional Center clients. The facilities’ annual fees are due on 01/18/2025 for $454.00.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) client bedrooms, two (2) common bathrooms, one (1) staff room, living room, dining room, kitchen, activity room, office area, and outdoor patio.

LPA conducted a records review of (4) client records, (5) staff records, and reviewed the facility disaster plan. All client & staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (4) Client Medication Administration Records and did not observe any discrepancies at the time of visit.

At 10:30am, LPA and the DSP toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, adequate storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations. Toilets and water faucets worked properly. The shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature measured 117.6F. A comfortable temperature is maintained in the facility.

Facility Evaluation Report Continued on LIC 809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: OLIVE'S HOME
FACILITY NUMBER: 198600454
VISIT DATE: 12/12/2024
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LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough perishable and non-perishable food available, which is stored properly. Medications were centrally stored and properly locked, first aid kit and manual were checked and fully stocked. The fire extinguishers (3) were charged and last inspected on 1/10/2024. Smoke/ Carbon Monoxide detectors were operable. The facility has current liability insurance, and it expires on 05/20/2025.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents. LPA observed that sanitizing stations were in common areas and restrooms. LPA observed that the facility had the required postings, posted throughout the facility. LPA further observed the facility to have a 60-day supply of Personal Protective Equipment (PPE).

LPA advised the administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing (www.cdss.ca.gov) for Provider Informational Notices (PIN) and for any updates relating to COVID-19 guidance and other related issues.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview was held, and a copy of the Facility Evaluation Report was provided to Rizalie Bondoc, Direct Support Staff.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC809 (FAS) - (06/04)
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