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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286804237
Report Date: 09/23/2025
Date Signed: 09/23/2025 02:23:37 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/17/2025 and conducted by Evaluator Julie Florio
COMPLAINT CONTROL NUMBER: 21-AS-20250617144049
FACILITY NAME:OLIVE HOUSE LLC, THEFACILITY NUMBER:
286804237
ADMINISTRATOR:BALAOY, ANYAFACILITY TYPE:
740
ADDRESS:1527 JUANITA STTELEPHONE:
(661) 476-7190
CITY:NAPASTATE: CAZIP CODE:
94559
CAPACITY:6CENSUS: 1DATE:
09/23/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Xiomara Robles, LicenseeTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not give proper notice for level of care rate change
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 09/23/2025, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver complaint #21-AS-20250617144049 investigation findings regarding the above allegation and met with Xiomara Robles, Licensee. Reporting Party (RP) alleges that the facility did not give proper notice for level of care rate change for Resident 1 (R1).

LPA Florio conducted 10-day complaint investigation visit on 06/19/2025 and obtained documents, made observations, and conducted interviews. During this visit, it was revealed through an interview with Licensee and through R1's updated appraisal needs and services plan dated 05/22/2025 that R1's care needs increased significantly from those intially reported by R1's family during the initial pre-placement appraisal and those indicated on R1's LIC602 Physcian's Report dated 04/15/2025 -- both reported occasional wandering and aggression, which facility staff later experienced as around the clock, everyday behaviors requiring inreased supervision of R1 and increased staffing needs.
Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2025
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 2
Control Number 21-AS-20250617144049
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: OLIVE HOUSE LLC, THE
FACILITY NUMBER: 286804237
VISIT DATE: 09/23/2025
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
Continued from LIC9099...

Subsequently, on 09/19/2025, LPA received copies of R1's admissions agreement dated 04/18/2025 and R1's admissions agreement addendum from Licensee which were sent to R1's responsible party via DocuSign on 05/31/2025 with the rate increase effective 06/01/2025. This addendum explained the change in condition and supervision needs of R1 noting changes in their sleeping patterns and daily and nightly elopement attempts. On 09/19/2025, LPA also received forwarded email communications dated 05/30/2025 between Licensee and R1's responsible party regarding a previous 30-day notice submitted by R1's child on May 1, 2025 via text message and the rate change with explanation should R1 remain in the facility. Based on observations made, interviews conducted, and records reviewed, the department received conflicting information.

Based on interviews conducted and records obtained, the allegation that facility did not give proper notice for level of care rate change for R1 is UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies cited.

Exit interview conducted with Licensee, whose signature on form confirms receipt of document(s).
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2