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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850353
Report Date: 07/15/2024
Date Signed: 07/15/2024 02:50:23 PM

Document Has Been Signed on 07/15/2024 02:50 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:OLIVE GROVE RESIDENTIAL CARE HOMEFACILITY NUMBER:
425850353
ADMINISTRATOR/
DIRECTOR:		CASTILLO, MARIBELFACILITY TYPE:
740
ADDRESS:1510 CALLE MIROTELEPHONE:
(805) 710-5304
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY: 6CENSUS: 3DATE:
07/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Reymar Castillo, Licensee TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 07/15/2024, Licensing Program Analyst (LPA) Brian Phillips arrived at the facility unannounced to conduct a required annual site inspection at the facility above. When the LPA arrived, they were greeted by Licensee Reymar Castillo as the Administrator was not available and informed them of the reason for the visit.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards
and facility is in compliance with Title 22 Regulations. This is a Residential Care For the Elderly (RCFE) facility, with an approved fire clearance for six (6) residents. The age range at this facility is 60 years old and over. The facility is approved for six (6) non-ambulatory residents with a hospice waiver approved for two (2) residents.

KITCHEN: The LPA inspected the kitchen/food service area and observed that knives/sharp instruments are
stored in a locked storage container in the kitchen. Kitchen appliances were in operable condition. The LPA
observed perishable items in good condition, with proper expiration dates precluding the perishable items from expiring. The facility has a sufficient supply of perishable and non-perishable food. Additional perishable food items were purchased prior to the visit and stored in the garage area on a shelf and/or an extra freezer. The hot water temperature was measured in the kitchen at an appropriate temperature as per the regulation. The Kitchen/food service and preparation area was very clean and everything appeared to be in good/operating condition.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good
condition. There is a fireplace in the living room, which is covered and inaccessible. The facility maintained a
comfortable temperature. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguishers were fully charged and are serviced annually. All exits from the facility either have delayed egress or locks which were all operational at the time of the visit. The LPA observed required postings throughout the common space. Continued on 809-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2024
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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: OLIVE GROVE RESIDENTIAL CARE HOME
FACILITY NUMBER: 425850353
VISIT DATE: 07/15/2024
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 There were two linen closets in the hallway with extra towels and fresh linens for residents.

OUTDOOR/BACKYARD: The backyard has an outdoor area equipped with furniture for resident use. There is a side gate which is delayed egress self-closing. All exits from the interior of the facility into the backyard area have accessibility ramps for residents. There were no bodies of water noted. There is a separate laundry room where cleaning products are stored, which is kept locked. The laundry room is accessible through the garage. There was emergency food and water in the garage which was observed to be in good condition. Cleaning supplies and disinfectants are kept in locked cabinets in the garage. In the front of the facility, the LPA noted that the facility had a delayed egress front gate outside into the driveway area, and the entire facility was gated. There is a locked storage shed in which extra accessibility/medical items are maintained for potential clients. This facility shares a common wall with an individual tenant not associated with the facility. This tenant maintains an apartment with no access to the interior of the facility, and no way to interact with residents of the facility.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are three designated resident rooms. One of the resident rooms has two beds and an attached bathroom. The other two resident bedrooms have individual beds, and the residents share a bathroom in the hallway. At the time of the visit, the facility has a designated staff room which also serves as an office for the licensee. Each closet in all of the resident rooms has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for future residents.

RESTROOMS: The two resident restrooms were clean and sanitary and in operating condition with grab bars
and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and
washcloths are not shared. The hot water temperature was measured in both of the restrooms at the
appropriate degrees Fahrenheit as per the regulations.

RECORDS: The facility keeps resident records on-site at the facility while Staff records were not stored on-site in the facility, but electronically by the Administrator/Licensee. Staff records were reviewed for Health Screening Report/Tuberculosis (TB) Clearance for facility personnel, Personnel Record (employment application), verification of age over 18 years old, education/experience, verification of first aid training, Criminal Record Statement, Criminal Record Clearance/Exemption, Verification of Staff training, Employee Rights, and Abuse Reporting Requirements. Continued on 809-C.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024
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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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: OLIVE GROVE RESIDENTIAL CARE HOME
FACILITY NUMBER: 425850353
VISIT DATE: 07/15/2024
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The administrator of the facility has an active RCFE Administrator Certificate that expires 10/06/2025. LPA observed that one (1) Staff member has no documentation of fingerprinting prior to beginning employment in the facility and no documentation of either a criminal record clearance or a criminal record exemption. All individuals subject to criminal record review do not have documentation of criminal record clearance or criminal record exemption in their individual personnel files. Resident records were reviewed for, but not limited to Pre-Admission/Placement appraisals, Resident Appraisals, Appraisal Needs and Services Plan (ANS), Physicians’ Reports, Identification and Emergency Information, Current Admission Agreement with signatures, Personal Rights for Residents, Record of Residents safeguarded cash resources, Record of Resident personal property/valuables, Responsible Person or Conservator of Resident, Self-management of medications if applicable, Medication Orders, and Medication Logs. All resident files reviewed by the LPA had the appropriate documentation included.

MEDICATIONS: Medications were reviewed for residents at the facility. Medications are stored in a centrally stored and locked closet in the hallway. The LPA observed the Licensee demonstrate the locking and unlocking of the centrally stored medication cabinet in the hallway. LPA observed the MARS and centrally stored medication logs for each resident and did not observe any deficiencies.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening and a
sanitation station. The staff members will keep up signs that promote good hand hygiene and symptoms of
COVID. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s
policies and procedures as it pertains to infection control are adequate.

FACILITY DOCUMENTATION: The facility keeps hard copies of the Application for an RCFE, Affidavit Regarding Client/Resident Cash Resources, Surety Bond, LIC 500 Personnel Report, LIC 501 Personnel Record, LIC 503 Health Screening Report, LIC 610E Emergency Disaster Plan for Residential Care Facilities For the Elderly, LIC 9282 Residential Infection Control Plan, LIC 999 Facility Sketch, and the Rental Agreement signed and dated 04/01/2023 with a copy of Cashier’s Check. The facility additionally has a Plan of Operation, Control of Property, Facility Program Description, Rules of Discipline/Personal Rights, Admission Agreement for Residents, Sample Food Menu, and the Theft & Loss Policy. Continued on 809-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024
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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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: OLIVE GROVE RESIDENTIAL CARE HOME
FACILITY NUMBER: 425850353
VISIT DATE: 07/15/2024
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The facility has on file a Dementia Care Plan document as well as Hospice Care Waiver. The Hospice Care Waiver states the maximum number of Hospice residents which the facility is requesting at any one time is two (2).

Deficiencies were cited for the facility having one (1) employee required to be fingerprinted pursuant to Section 87355, having no documentation of fingerprinting with no documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e). All personnel records are not maintained at the facility and not available physically at the facility for LPA to to inspect, audit, and copy. However, personnel records were available to LPA electronically as the Administrator/Licensee had to scan the Personnel Records from a separate location after a delay. Technical violations were issued to the facility as all individuals subject to criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working in a licensed facility request transfer of criminal record clearance as specified in Section 87355 or request and be approved for transfer of criminal record exemption as specified in section 87356(r). Licensee shall receive Criminal Record Clearances/Criminal Record Exemptions for all Staff at facility.

Exit interview conducted. A copy of the report was issued/provided to the facility.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024
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Document Has Been Signed on 07/15/2024 02:50 PM - It Cannot Be Edited


Created By: Brian Phillips On 07/15/2024 at 02:33 PM
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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OLIVE GROVE RESIDENTIAL CARE HOME
FACILITY NUMBER: 425850353

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)(13)(B)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above when one (1) employee required to be fingerprinted, had no documentation of fingerprinting with no documentation of either a criminal record clearance or a criminal record exemption, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/16/2024
Plan of Correction
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Licensee shall not allow Staff Louie Tuon to work at facility without required fingerprinting submitted to DOJ/FBI pursuant to Criminal Record Clearance. Licensee shall receive Criminal Record Clearances/Criminal Record Exemptions for all Staff at facility.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kelly Burley
LICENSING EVALUATOR NAME:Brian Phillips
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/15/2024 02:50 PM - It Cannot Be Edited


Created By: Brian Phillips On 07/15/2024 at 02:33 PM
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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OLIVE GROVE RESIDENTIAL CARE HOME
FACILITY NUMBER: 425850353

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and record review, the licensee did not comply with the section cited above as Personnel Records are not available at the facility for LPA to inspect, audit, and copy. Personnel records needed to be scanned electronically by Administrator/Licensee from a separate location after a lengthy delay, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2024
Plan of Correction
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Licensee shall maintain all Staff/Personnel files at the facility to be available for Licensing Agency to inspect, audit, and copy upon demand during normal business hours.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kelly Burley
LICENSING EVALUATOR NAME:Brian Phillips
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2024


LIC809 (FAS) - (06/04)
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