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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005572
Report Date: 02/02/2023
Date Signed: 02/02/2023 10:51:26 AM

Document Has Been Signed on 02/02/2023 10:51 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
ORANGE & INLAND A/SC, 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:
02/02/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Francisa Diaz, AdministratorTIME COMPLETED:
11:10 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ruth Martinez conducted a case management visit on today's date. LPA arrived at facility was greeted and granted entry by caregiver. LPA met with Francisca Diaz, Administrator and explained the nature of the visit.

On 01/23/2023 LPA Alejandre received a call from Administrator informing department that the facility has all private rooms, and a wall was placed dividing a family room without seeking CCLD prior approval or building permit. LPA Alejandre advised Administrator to submit an LIC200, proposed floor plan and a check for the fees to the department. Administrator informed that license is currently licensed under an individual, however Administrator indicated they had incorporated.

During today’s visit LPA toured the physical plant of the facility with Administrator and observed facility to have two family rooms, one in the main entry of the facility and another one adjacent to it. Administrator stated a wall was put up to split the room and make a private bedroom. LPA observed the room to be empty with no furnishing or occupancy. LPA advised Administrator that bedroom cannot be occupied until process is finalized and fire clearance is granted. LPA Martinez reviewed the facility floor plan and it does not match the actual physical plant. LPA was informed that Administrator submitted the LIC200, proposed floor plan and check to CCLD on 01/24/2023. Administrator provided a copy of the receipt from the department. Administrator showed LPA Martinez an LIC309 that was mailed into CCLD dated 11/27/2019 for the LLC that was created. LPA Martinez explained that in order for the facility to be under the LLC that a change or ownership application needed to be submitted to the department. Administrator indicated she never received any call or correspondence from the department, but she will call the centralized applications bureau and verify.

Continued on LIC809-C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: OLIVE TREE HOME CARE
FACILITY NUMBER: 306005572
VISIT DATE: 02/02/2023
NARRATIVE
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In the event that the paperwork is not filed or needs to be filed she will submit the required to the department no later than March 02, 2023.

Based on this inspection, deficiencies were observed at this time in the areas evaluated per Title 22 Division 6 of the California Code of Regulations. See LIC 809-D for deficiencies.

This report was reviewed with Administrator and a copy of this LIC809, LIC809-D report was provided and left at facility. Appeal rights reviewed, and a copy provided.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

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

DATE: 02/02/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/02/2023 10:51 AM - It Cannot Be Edited


Created By: Ruth Martinez On 02/02/2023 at 10:17 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: OLIVE TREE HOME CARE
FACILITY NUMBER: 306005572

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/03/2023
Section Cited
CCR
87305(a)

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Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not being met as evidenced by: Based on physical plant tour, observations on LIC999 floor plan, and information obtrained from Administrator. Licensee failed to ensure above indicated was obtained before making changes to
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LIcensee to submit an LIC200, proposed floor plan, and fees to department by POC due date.

During visit Adminsitrator provided a receipt for the fees paid for the submitted forms. Administrator indicated the paperwork was submitted on 1/24/2023.
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to the physical pant of the facility. This poses an immediate health and safety risk to residents in care.
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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:Armando J Lucero
LICENSING EVALUATOR NAME:Ruth Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023


LIC809 (FAS) - (06/04)
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