<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197605898
Report Date: 08/02/2023
Date Signed: 08/02/2023 03:48:08 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/01/2023 and conducted by Evaluator Alma Gonzalez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230801085613
FACILITY NAME:OLYMPIC BOARD & CAREFACILITY NUMBER:
197605898
ADMINISTRATOR:JURATE EZERSKIENEFACILITY TYPE:
740
ADDRESS:4532 ABBEY PL.TELEPHONE:
(323) 936-1018
CITY:LOS ANGELESSTATE: CAZIP CODE:
90019
CAPACITY:6CENSUS: 5DATE:
08/02/2023
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Justina MillanTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Unlawful eviction.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegations. LPA met with House Manager Justina Millan and explained the reason for the visit.

The investigation consisted of: LPA conducted interviews with House Manager Justina Millan, Resident 1 (R1) and with R1 Family Member (R1 FM) by telephone. LPA collected copies of Staff and Resident Rosters, reviewed R1's file and collected copies of documents pertinent to the investigation.



(See LIC9099C for continuation)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023
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 2
Control Number 28-AS-20230801085613
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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: OLYMPIC BOARD & CARE
FACILITY NUMBER: 197605898
VISIT DATE: 08/02/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Investigation revealed the following: Regarding allegation, Illegal Eviction, it is alleged that a facility resident was transported to the hospital on 07/31/2023 for confusion and fatigue and was discharged on the same day but facility staff stated to hospital staff that they would not be accepting the resident back to the facility. Interview with House Manager revealed that they did not state that they would not accept the resident back but only informed hospital staff that they had to do a reassessment before the resident returned to the facility. House Manager stated that hospital staff was not understanding and just assumed that the facility was not taking the resident back. House Manager stated that R1 was reassessed on 08/1/23 and returned back to the facility on 08/1/23. House Manager stated that R1's health has declined during the past year and the facility will be issuing an eviction notice due to facility can no longer meet the needs of R1. House Manager stated that the eviction notice has not been served yet and once it is served to the resident and R1's responsible party, she will send a copy to CCLD for review. LPA observed that R1 was last reassessed on 08/01/23. LPA observed R1 at the facility. R1 stated that they have not been served an eviction notice but stated that staff have mentioned to them that their health has declined and they need a higher level of care. LPA also spoke to R1's family member (R1FM) who stated that R1 has not been served an eviction notice. Based on interviews conducted with facility staff, facility resident and family member, and LPA review of documents there was not enough supportive evidence to concur with the reported allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview held. A copy of the report was provided to House Manager Justina Millan.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2