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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005572
Report Date: 01/04/2024
Date Signed: 01/04/2024 01:51:34 PM

Document Has Been Signed on 01/04/2024 01:51 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: 3DATE:
01/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Francisca DiazTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Administrator Francisca Diaz and explained the reason for the visit. Francisca Diaz's Administrator's Certificate expires on 10/07/2024. Facility is a single story home with 7 bedrooms (1 room is for staff), 6 bathrooms, living room, dining room, family room, laundry room, eat in kitchen and a two car attached garage. The family room and living both have fireplaces that are screened. LPA observed the See Something, Say Something poster (PUB 475) posted in the entry way of the facility. LPA and Administrator toured the facility. LPA observed all resident rooms have the required furnishings. LPA observed a 2-day perishable and a 7 day non-perishable food supply on hand. LPA observed emergency food and water supply stored in the laundry room. The kitchen is clean and organized. LPA observed the refrigerator in the kitchen in empty and is not working. The Administrator reported they are using the refrigerator in the laundry room and the one in the kitchen dining area. LPA observed the refrigerators in the laundry room and kitchen dining area are operational and both have a 2-day supply of perishable food. Medications and sharp objects are kept secured and inaccessible to residents. LPA observed the cleaning supplies are kept secured in the laundry room. Hot water in all bathrooms measured between 114.0 degrees Fahrenheit and 120.0 degrees Fahrenheit. The carbon monoxide/smoke detectors tested operational. LPA observed all fire extinguishers are fully charged. The garage is used for storage and is inaccessible to residents. LPA and Administrator toured the backyard. The backyard has covered patio with a seating area. The backyard has a pool which is fenced and inaccessible to residents. There is a storage room and a storage shed in the Backyard. LPA observed both are used to store old furniture and supplies. The storage room and storage shed are kept locked. The exit gates on each side of the house are operational and self latching. No obstacles or hazards observed inside or outside of the facility. LPA reviewed 4 out of 4 resident files. All of the resident files had the required documents with no deficiencies observed. LPA reviewed all 4 residents medication, no discrepancies observed. LPA reviewed 2 staff files. Both staff files had the required documents and no deficiencies observed. Both staff members had the required 20 hours of annual training.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
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 CARE
FACILITY NUMBER: 306005572
VISIT DATE: 01/04/2024
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LPA interviewed one staff member. Residents were resting, no resident interviews were conducted. 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: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024
LIC809 (FAS) - (06/04)
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