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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600559
Report Date: 07/18/2023
Date Signed: 07/18/2023 11:47:08 AM

Document Has Been Signed on 07/18/2023 11:47 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:OLIVE HOUSE, THEFACILITY NUMBER:
198600559
ADMINISTRATOR:ELAM, ANNA MARIEFACILITY TYPE:
735
ADDRESS:631 NORTH OLIVE AVENUETELEPHONE:
(626) 872-0342
CITY:ALHAMBRASTATE: CAZIP CODE:
91801
CAPACITY: 4CENSUS: 4DATE:
07/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:37 AM
MET WITH:Asfunso Elam - Assistant Administrator TIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE tool. LPA met with Asfunso Elam Assistant administrator and explained the reason for the visit.

The facility is licensed for four (4) Developmentally Disabled Adults, ages 18 to 59. Two (2) of the four (4) may be non-ambulatory. The facility is a one story house with 2 shared client bedrooms, 1 client bathroom, living room, dining room, kitchen, family room, a staff room, a staff bathroom, and an attached garage.

LPA Flores conducted a tour of the facility with Asfunso Elam and observed the following:
Facility is in good repair inside and outside. Living room has a cover fireplace. Dining room has a medication cabinet under lock. Kitchen was observed clean, cleaning supplies, and sharps are kept in a closet next to the laundry area with a lock during the visit. Refrigerator was observed and temperature was observed at 55 degrees F. which is not within the recommended to at least 45 degrees F. Sufficient food supplies were observed for at least 2 days of perishables and 7 days of non-perishables. Family room has a cabinet with activity materials. Client bedrooms (2) have sufficient lighting, required furniture and bedding. Bathroom was observed in working condition, water temperature was tested at 102.9 degrees F. which is not within the required 105-120 degrees F. Freezer was observed in the garage at 0 degrees F. which is within the recommended temperature. Smoke/Carbon monoxide detectors were tested and in working condition. Fire extinguisher was observed and last checked on 7/15/23.

LPA reviewed medication and files for 4 clients, and 5 staff files. Administrator certificate #6013989735 exp date: 6/15/23 was submitted for renewal and it is pending. Emergency Disaster Plan (10/03) was observed and additional plan which did not meet the required fields. Last fire drill was conducted on 6/20/23. Per administrator an infection control plan was submitted to the department on 7/10/23. Interview 2 staff and 1 client.
Deficiencies are noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Asfunso Elam and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023
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
Document Has Been Signed on 07/18/2023 11:47 AM - It Cannot Be Edited


Created By: Mary G Flores On 07/18/2023 at 10:48 AM
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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: OLIVE HOUSE, THE
FACILITY NUMBER: 198600559

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in water temperature tested in bathroom #1, tested at 102.9 degrees F. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2023
Plan of Correction
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Administrator will adjust water temperature and will maintain a daily water log for 7/19/23 - 8/1/23 and will submit a copy to the department by POC due 8/1/23.
Type B
Section Cited
CCR
85076(d)(3)
Food Service
(3) Refrigerators shall be large enough to accommodate required perishables and shall maintain a maximum temperature of 45 degrees F (7.2 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in refrigerator's temperature was observed at 55 degrees F. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2023
Plan of Correction
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Administrator will adjust refrigerator's temperature, will maintain a log for 7/19/23 - 8/1/23 and will submit a copy of log and a picture of thermometer at correct temperature by POC due date 8/1/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/18/2023 11:47 AM - It Cannot Be Edited


Created By: Mary G Flores On 07/18/2023 at 10:48 AM
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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: OLIVE HOUSE, THE
FACILITY NUMBER: 198600559

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in LIC 610 (10/03) was reviewed during this visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2023
Plan of Correction
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Administrator will update LIC 610 to version (12/21) to meet the departments disaster prepareness and will submit a copy to the department by POC due date 8/1/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023


LIC809 (FAS) - (06/04)
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