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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005572
Report Date: 03/16/2022
Date Signed: 03/16/2022 03:49:39 PM

Document Has Been Signed on 03/16/2022 03:49 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:OLIVE TREE HOME CAREFACILITY NUMBER:
306005572
ADMINISTRATOR:DIAZ, FRANCISCAFACILITY TYPE:
740
ADDRESS:638 N JAMES PLTELEPHONE:
(714) 726-3724
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 6DATE:
03/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Francisca DiazTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation). LPA was screened for symptoms of Covid-19 and granted entry. LPA explained the reason for the visit. LPA met with Administrator Francisca Diaz. Administrator's Certificate expires on 10/07/22. LPA and Administrator toured the facility. Facility has 6 bedrooms, 1 is for staff, 6 bathrooms, living room, dining room, kitchen and a 2 car garage. LPA observed the PUB 475 poster (See Something, Say Something) is in the hallway away from the front entrance and is 8 1/2 X 11 inches. LPA observed all of the resident rooms had the required furnishings. Bathrooms were clean and operational. LPA observed a 2 day supply of perishable food and a 7 day supply of non-perishable food on hand in the kitchen. LPA observed knives are kept locked in the kitchen. LPA observed medications are kept locked in a kitchen cabinet. LPA and Administrator toured the backyard. The backyard has a covered patio with a seating area for residents . There is a swimming pool in the backyard. LPA observed the swimming pool is fenced and the both gates are locked, There is a shed in the backyard. The shed is used for storage and kept locked. Both exit gates on each side of the house are operational. There is a storage shed on the side of the house. The side storage shed is empty and kept locked. LPA observed the garage is used for storage and kept locked. Smoke detectors/carbon monoxide detectors tested operational. The last emergency drill was conducted on 12/13/21. LPA inspected the First Aid Kit. The First Aid Kit has all the required elements. Facility has a mitigation plan that is pending approval. No deficiencies observed during the visit. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2022
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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