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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005572
Report Date: 03/19/2026
Date Signed: 03/19/2026 01:47:37 PM

Document Has Been Signed on 03/19/2026 01:47 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:OLIVE TREE HOME CAREFACILITY NUMBER:
306005572
ADMINISTRATOR/
DIRECTOR:		DIAZ, FRANCISCAFACILITY TYPE:
740
ADDRESS:638 N JAMES PLTELEPHONE:
(714) 726-3724
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 4DATE:
03/19/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:44 PM
MET WITH:Administrator Francisca DiazTIME VISIT/
INSPECTION COMPLETED:
04:18 PM
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Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit to complete the required annual inspection. Upon arrival, LPA met with Administrator Francisca Diaz and explained the purpose of the visit. LPA toured the interior and exterior areas of the facility with the Administrator and observed the following:

The facility is a single-story home consisting of seven bedrooms, including one staff room, six bathrooms, a living room, dining room, family room, laundry room, eat-in kitchen, and an attached two-car garage.

The kitchen was observed to be in good repair. Cleaning supplies and sharp objects were stored in a manner that made them inaccessible to residents in care. Medications were kept locked in a separate hallway cabinet. LPA reviewed the files and medications for two residents and found no discrepancies. Staff and resident files were also reviewed and were found to contain all required documentation. Record review showed that the facility is current with required quarterly fire drills, with the most recent fire drill conducted on January 21, 2026. LPA also observed that the PUB 475 poster was posted and met the required regulatory size.

Resident bedrooms were observed to be furnished with beds, chairs, clean linens, and adequate storage space. The rooms were free of tripping hazards. Manual smoke detectors, carbon monoxide detectors, and exit alarms were tested and found to be operational. Bathrooms were in good repair and equipped with grab bars. {***CONTINUE 809C***}

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Samer Haddadin
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: OLIVE TREE HOME CARE
FACILITY NUMBER: 306005572
VISIT DATE: 03/19/2026
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Hot water temperatures in the bathrooms measured between 114.0 and 118.9 degrees Fahrenheit. The facility also met the minimum food supply requirements of at least a two-day supply of perishable food and a seven-day supply of nonperishable food.

The fire extinguisher was fully charged, with the indicator in the green zone. The exterior grounds were observed to be in good condition, with outdoor furniture in good repair, free of tripping hazards, and providing ample space for activities. The backyard pool was fenced and inaccessible to residents. LPA observed a storage room and storage shed in the backyard, both of which were used to store old furniture and supplies. Both storage areas were locked.

No deficiencies were cited during today’s annual inspection. An exit interview was conducted, and a copy of this report was provided to the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Samer Haddadin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026
LIC809 (FAS) - (06/04)
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