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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600559
Report Date: 06/04/2024
Date Signed: 06/04/2024 02:53:37 PM

Document Has Been Signed on 06/04/2024 02:53 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:OLIVE HOUSE, THEFACILITY NUMBER:
198600559
ADMINISTRATOR/
DIRECTOR:		ELAM, ANNA MARIEFACILITY TYPE:
735
ADDRESS:631 NORTH OLIVE AVENUETELEPHONE:
(626) 872-0342
CITY:ALHAMBRASTATE: CAZIP CODE:
91801
CAPACITY: 4CENSUS: 4DATE:
06/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:21 AM
MET WITH:Anna Marie Elam, Administrator and Asfunso ElamTIME VISIT/
INSPECTION COMPLETED:
01:57 PM
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced annual visit at the facility using the CARE tool. LPA met with Anna Marie and Asfunso Elam 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 Lopez conducted a tour of the facility with Ana Marie and Alfunso Elam and observed the following:
Facility is in good repair inside, outside needs touch up paint in some parts as paint chipping. Living room has a cover fireplace. Dining room has a medication cabinet under lock. All clients PRN medications are missing PRN authorization letters. Kitchen was observed clean, cleaning supplies, and sharps are kept in a closet next to the laundry area with a lock. 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 114.4-116.4 degrees F. which is 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. Client cash resource log needs to be updated.

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 needs updating. Last fire drill was conducted on 12/07/2023. Per administrator an infection control plan was submitted to the department on 7/10/23. LPA interview 2 staff and 1 client.
Deficiency noted on LIC 809D per Title 22 Regulations. Technical advisories also provided. Exit interview was conducted with Asfunso Elam and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2024
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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Document Has Been Signed on 06/04/2024 02:53 PM - It Cannot Be Edited


Created By: Alberto Lopez On 06/04/2024 at 01:29 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
, 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: 06/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee, administrator, or regulated individual shall sign and date the documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above Emergency disaster plan has former staff listed for responsibilities. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/07/2024
Plan of Correction
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Administrator will update disaster plan and send LPA updated version by POC date.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2024


LIC809 (FAS) - (06/04)
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