Olive Tree Home

Type of visit: Required - 1 Year

On 12/01/2025 at 11:20am, Licensing Program Analyst (LPA) Zina Brown conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Romina Ocampo (Direct Care Staff) and Rommel Dungca (Licensee)and explained the purpose of today’s visit. The facility is licensed to serve (18) elderly adults ages 60 and above, of which (18) can be non-ambulatory. The facility has an approved hospice waiver for (4). The facility has a current administrator certificate (7033913740) for Rommel Dungca valid 07/09/2025 - 07/08/2027. The facility fees balance is at $0. The liability insurance is current and is valid from 02/10/2025 - 02/10/2026 with James River Insurance Company (NAIC # 12203) - policy # #00140336-2. The one-story residential home consists of ten (10) resident bedrooms, two (2) resident bathrooms, living room, dining room, family room, kitchen, office area, washer and dryer/ storage area, backyard with table and chairs. Between the hours of 11:30am - 1:45pm, LPA conducted a records review of (7) client records, (5) staff records, (3) clients Personal & Incidental Records and reviewed the facility disaster plan. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (7) Client Medication Administration Records and did not observed any discrepancies at the time of visit. Between the hours of 12:05pm - 12:30pm, LPA Brown and Rommel Dungca toured the inside and outside of the facility. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed, plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105 -120F (115.7F in Bathroom 1). The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide detector was observed and operational. Smoke detectors were working properly, fire extinguishers were fully charged, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Outside grounds were toured and no bodies of water were observed. Exits/ Walkways around the home were free of debris and hazards. During todays visit LPA did observe a deficiencies. Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below: 1. Medical Assessment 87458: Resident 5 (R5) and Resident 6 (R6) did not have TB Test Result on file at the time of annual inspection visit. 2. Maintenance and Operation Section 87303(f) - Standard: In Room 8 multiple gnats on cup filled with coffee inside and outside of the cup 3. General Food Service Requirements Section 87555(b)(27): In the kitchen near sink area, multiple gnats flying around. Note: *If citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. * An exit interview was conducted, and a copy of the Facility Evaluation Report with Appeal Rights was provided to Romina Ocampo (Direct Care Staff).the state’s words, verbatim · CDSS document, Dec 1, 2025

Allegation investigated: Facility staff are not safeguarding resident belongings. Facility staff did not ensure to provide a safe environment for residents in care.

On 8/18/25 Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA Shirley arrived and spoke to staff, Romina Ocampo and the purpose of the visit was discussed. LPA was granted access to the facility. The investigation consisted of the following: On 8/18/25 LPA requested and reviewed copies of the following records: Resident file, Resident Roster, LIC 500, Resident Face Sheet, Admission Agreement, Physician’s Report, Client/Resident Personal Property and Valuables list (LIC 621), Weekly Laundry Schedule, Unusual Incident/Injury report. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff-4. Resident 1 – Resident 5. The investigation revealed the following: Con'd on 9099-C Unsubstantiated Allegation: Facility staff are not safeguarding resident belongings. It is alleged that R-1 was missing a pair of jeans and a hat was stolen. During interviews, on 8/18/25 LPA Felisa Shirley ask S-1 if this facility had a lost and found and was told no it does not. LPA Shirley reviewed R-1’s facility file. Per resident’s admission agreement, R-1 has been a resident at the above named facility since 1/2/24. LPA Shirley reviewed R-1’s Client/Resident Personal Property and Valuables (LIC 621) list. On the list, “Wish Not to List” was written in the description section and the form was signed by R-1 on 1/2/24. LPA Shirley toured the facility went to the laundry room in search of R-1’s missing items and did not observe any misplaced jeans. LPA Shirley went to R-1’s room and conducted a search of said missing items. LPA Shirley observed that there were 2 pairs of jeans hanging in the closet, a folded pair of jeans in R-1’s drawer and on 8/18/25, R-1 was wearing a pair of jeans. LPA observed 4 baseball caps in one drawer and 1 black leather hat underneath some clothes in another drawer. LPA interviewed staff 1 – staff 4 (S-1 – S-4). Of those interviewed 4 out of 4 denied the allegation. LPA interviewed Resident 1 – Resident 5(R-1 – R-5). Of those interviewed 5 out of 5 denied the allegation. Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Facility staff did not ensure to provide a safe environment for residents in care. It is alleged that R-1 initiated an alteration due to the theft of R-1’s belongings. All residents that were interviewed, 5 out of 5 stated that they have never had a physical altercation with any of the residents. LPA Shirley reviewed the facilities incident reports for 2025 and observed that R-1 was the sole aggressor in the reported altercations against other residents. Per interview with S-1, in all situations staff is always on stand by to assist when needed to all residents in care. Per LPA observation, there is an appropriate staff to resident ratio noting that the facility does have enough staff to supervise the residents in this facility. Con'd on 9099-C LPA interviewed staff 1 – staff 4 (S-1 – S-4). Of those interviewed 4 out of 4 denied the allegation. LPA interviewed Resident 1 – Resident 5(R-1 – R-5). Of those interviewed 4 out of 5 denied the allegation. One resident confirmed the allegation. Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to staff, Romina Ocampo.the state’s words, verbatim · CDSS document, Aug 18, 2025 · control 11-AS-20250813135605

Allegation investigated: Due to lack of supervision, resident physically assaults other residents.

On 2/21/25, at 9:30am, Community Care Licensing Division (CCLD) Staff conducted an initial complaint visit to the facility and was greeted by Cezar Tuazon, Direct Care Staff. CCLD explained the purpose of this visit is to gather information about the complaint, interview staff and residents, and deliver findings for the allegation mentioned above. The investigation consisted of the following: An initial complaint visit was completed by (CCLD) staff on 2/21/2025. The department investigated the allegation mentioned in this complaint; and conducted interviews with staff (S1-S2) and residents (R1-R7). Staff Roster (Dated: 10/30/24), Resident Roster (Dated: 10/30/24), ID/Emergency Information (Dated: No Date), and Face Sheet (Dated: No Date) were obtained from the facility. The investigation revealed the following: Allegation- Due to lack of supervision, resident physically assaults other residents. Complaint Investigation Report On LIC9099-C Unsubstantiated The details of the complaint alleged that the facility does not provide adequate supervision of the residents. It is alleged that resident (R1) assaulted resident (R2) at the facility with their walker. On 02/21/25, from 9:30am-1:30pm, the department interviewed staff (S1-S2) and residents (R1-R7) regarding the allegation. 2 of 2 staff denied the allegation that Due to lack of supervision, resident physically assaults other residents. All staff (S1-S2) interviewed stated that the facility does have enough staff to supervise the residents in the facility. All staff (S1-S2) denied the allegation that residents are assaulting each other. Staff stated that there was an incident where a resident was praying with their hands to the sky and another resident tried to put their hands down. Staff stated that the resident was not aware of what the other resident was doing and did not know that they were praying. Staff stated that they explained what the resident was doing and not to try and put the residents’ hands down because it was not right to do so. Staff stated that the resident apologized, and it was okay between them after that. But that the resident did not assault or hit the other resident at any time. Staff also stated that they did not witness resident (R1) hit resident (R2) with their walker. The department interviewed residents (R1-R7) about the allegation and 7 of 7 residents that were interviewed denied the allegation that Due to lack of supervision, resident physically assaults other residents. All residents that were interviewed (7 of 7) stated that they have never been assaulted by any resident at the facility and there is enough staff to supervise the residents in the facility. The department interviewed R1 and R2 about any alleged altercation between the two and both denied any knowledge of an altercation and R1 denied that R1 hit R2 with their walker. R2 also denied that R1 hit R2 with their walker. The department reviewed the Staff Roster (Dated: 10/30/24) and observed that there is enough staff on the day and night shift to supervise the residents properly. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegation that Due to lack of supervision, resident physically assaults other residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No citations were issued on this complaint visit. An exit interview was conducted, and a hard copy of this Complaint Investigation Report was provided to Cezar Tuazon, Direct Care Staff.the state’s words, verbatim · CDSS document, Feb 21, 2025 · control 11-AS-20250214082212

Allegation investigated: Staff did not safeguard resident funds.

On 10/30/24, at 9:30am, Licensing Program Analyst (LPA) Perry Scott conducted an initial complaint visit to the facility and was greeted by Cezar Tuazon Jr., Direct Care Staff, and later by Rommel Dungca, Administrator. LPA explained the purpose of this visit is to conduct interviews, gather facility files, and render findings in the complaint. The investigation consisted of the following: LPA investigated the allegation mentioned in this complaint and conducted interviews with staff (S1-S3) and residents (R1-R7). Additionally, LPA obtained the following documents: Resident Roster (Dated: 7/05/2024), Staff Roster (Dated: 9/13/2023), Admission Agreement (Dated: 06/27/2022), Physicians Report (Dated: 06/02/2022), ID/Emergency Information (Dated: 06/28/2022), Appraisal/Needs And Services Plan (Dated: 06/28/2022), Client/Resident Personal Property And Valuables (Dated: 06/28/2022), Safeguarded Cash Resources (Dated: 08/06/2024-10/22/2024), Surety Bond (Dated: 10/28/2022), House Rules (Dated: No Date), and Visitation Sign in Sheet (Dated: 09/19/2024-10/30/2024) from the facility. Complaint Investigation Report Continued on LIC9099-C Unsubstantiated The investigation revealed the following: Allegation-Staff did not safeguard resident funds. The details of the complaint alleged that the resident’s wallet was stolen by another resident in the facility that contained about $500.00. On 10/30/24, from 09:00am-2:00pm, LPA interviewed staff (S1-S3) and residents (R1-R7) regarding the allegation. 3 of 3 staff (S1- S3) denied the allegation that the facility Staff did not safeguard resident funds. All staff (S1-S3) stated that the facility does safeguard the residents’ funds. They state that the facility has a safe that safeguards their P & I money. Staff stated that the resident (R1) misplaced R1s wallet and they looked for the wallet but could not find it. The staff denies that the wallet contained $500.00 because according to staff, all R1s money from R1s P & I funds are kept in the safe. They state the resident has $1,716.00 available. They also state that P & I funds are issued on the 1st or the 3rd of each month. And once the funds are distributed, the residents must sign for it. The department reviewed the Safeguarded Cash Resources (Dated: 08/06/2024-10/22/2024) and observed that R1 was supposed to have $1,716.00 in P & I money. The department had the staff count the cash for R1 that was locked in the facility safe, and verified the amount was accurate with R1s signatures. The department also observed the Client/Resident Personal Property and Valuables (Dated: 06/28/2022) and noted that R1 had no valuables listed. LPA interviewed residents R1-R7 about the allegation and 6 of 7 residents that were interviewed denied the allegation that the facility Staff did not safeguard resident funds. The majority of the residents (6 of 7) interviewed stated that the facility does safeguard their funds and have not had an issue with theft in the facility. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff did not safeguard resident funds. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No citations were issued for this complaint. An exit interview was conducted with Cezar Tuazon Jr., Direct Care Staff, and a copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Oct 30, 2024 · control 11-AS-20241022135922

Type of visit: Required - 1 Year

On 10/19/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Cezar Tuazon /Facility Staff. LPA explained the purpose of today’s visit. The facility is licensed to serve (18) elderly adults ages 60 and above, of which (18) can be non-ambulatory. The facility has an approved hospice waiver for (4). The one-story residential home consists of ten (10) resident bedrooms, two (2) resident bathrooms, living room, dining room, family room, kitchen, office area, washer and dryer/ storage area, backyard with table and chairs. LPA Iniguez and facility staff toured the physical plant. There were no bodies of water or obstructions on the premises. LPA inspected a total of (9) bedrooms and (2) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 113.5°F to 115.2°F, and the room temperature ranged from 76°F to 78°F. The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings. During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 7/15/24. A review of (5) residents' service files and (3) staff personnel files was maintained in order. LPA reviewed (5) Medication Administration Records (MARs) and found no discrepancies. LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance will be email to LPA. Facility Annual Fess current. Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below: -No facility staff available for approximately 30 minutes. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. * An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Cezar Tuazon / facility staff.the state’s words, verbatim · CDSS document, Oct 19, 2024

Allegation investigated: Staff are not properly addressing bed bug infestation in facility

On 06/24/2024 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the above-mentioned facility. LPA was met by Cezar Tuazon, Direct Support Professional (DSP) (S1) and the purpose of the visit was explained. S1 and LPA toured the facility. The investigation consisted of the following: On 06/24/2024 LPA requested and reviewed facility documents and toured the facility. LPA interviewed two (2) out of sixteen (16) residents and one (1) out of three (3) staff. The investigation revealed the following: Regarding the allegation: "Staff are not properly addressing bed bug infestation in facility.". It has been alleged that one resident had been observed to have bed bugs on their body. Between 09:00AM and 10:30AM, on 06/24/2024, LPA observed one (1) bed bug exoskeleton and one (1) live bed bug in a resident's bed in the resident's room (room six). Report continues, see LIC9099C Substantiated Interviews revealed that 1 out of 1 staff and 1 out of two (2) residents have agreed with the allegation. Record reviews revealed that the last pest control visit was conducted on 06/25/2022. Based on LPA's observations, record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC 9099D. An exit interview was held with Cezar Tuazon, DSP, and a copy of appeal rights and this report has been provided.the state’s words, verbatim · CDSS document, Jun 24, 2024 · control 11-AS-20240619112759

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jun 28, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. The licensee did not comply with the section cited above in staff knowing there were bed bugs which were not dealt with through a commercial pest exterminator. This poses a potential Health, Safety or Personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 24, 2024

Plan of correction: The licensee has agreed to update the house rules, to include "Residents shall not bring in any outside items, which includes clothing that has not been sanitzed at 120 degrees F or above." In addition, licensee has agreed to contact a commercial exterminator and follow the guidance provided by this commercial exterminator to prevent any future occurance of infestation at the facility. Licensee will send a copy of the updated facilities' house rules and all exterminator visits and recommendation provided by exterminator to LPA at MARIO.LEON@DSS.CA.GOV

Type of visit: Required - 1 Year

On 12/06/2023 at 09:30 AM, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced annual inspection visit at the Olive Tree Home Facility. LPA Calderon was allowed entry into the facility by Staff Cesar Tuazon. Staff Cesar Tuazon was asked questions regarding the full care tools control package (13) sections. Staff Cesar Tuazon took LPA Calderon temperature prior to entrance into the facility. The facility is licensed for (18) non-ambulatory adult clients. Currently, there are (16) non-ambulatory residents residing in the facility. LPA Calderon explained to Staff Cesar Tuazon, the purpose of the one-year (1) Annual Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: three (3) resident service records, three (3) resident medication records, three (3) staff records. LPA Calderon interviewed three (3) residents and three (3) staff members for visit. LPA Calderon inspected the inside facility and outside grounds to include all common areas. The facilities’ last fire drill was conducted on 04/26/2023. The one-story residential home consists of ten (10) resident bedrooms, two (2) resident bathrooms, living room, dining room, family room, kitchen, office area, washer and dryer/ storage area, backyard with table and chairs. No weapons are stored in the premises. Kitchen was inspected and observed to be clean and operational. A two-day (2) supply perishable and seven-day (7) supply of non-perishable foods are present in the facility. Emergency Water seven-day (7) supply is found in the kitchen. LPA Calderon observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA Calderon observed the following during inspection of resident’s rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA Calderon observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 106 degrees Fahrenheit. Bathroom #2 hot water temperature properly measured at 108 degrees Fahrenheit. Kitchen hot water temperature properly measured at 115 degrees Fahrenheit. Facility (2) carbon Monoxide and (13) Smoke Detectors hard wired and were tested and are working properly. The facility three (3) Fire Extinguishers were checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. All toxins and knifes are locked/secured and inaccessible to residents. Medications are centrally stored and in a locked storage cabinet. Facility first aid kit (2) is fully stocked with manual was checked and in order. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to residents. LPA Calderon reviewed three (3) resident files and found to be complete. LPA Calderon reviewed three (3) resident medications and they were all found to be administered according to doctor's orders. Three (3) staff files were checked and have the required documents. LPA Calderon noted the Administrator Rommel Dungca Certification # 6001081740 expiration date of 07/08/2023 was NOT valid at time of visit. The facility does handle resident's money/cash resources and Surety bond is needed. Commercial General Liability Policy #001403360 policy period from 02/10/2023 to 02/10/2024 underwritten by James River Insurance Company, coverage 1,000,000/3,000,000 is valid at time of inspection. LPA Calderon spoke to Administrator Rommel Dungca who will email full copy of insurance contact which shows all coverages to LPA Calderon on 12/20/2023. All the required documents are posted in the facility in a clearly visible area to all staff, clients, and guests. LPA Calderon reviewed LIC500 and noted all staff associated to facility per LIS. LPA Calderon reviewed the resident roster, LPA Calderon confirmed residents’ interview are on resident roster. During the visit, LPA Calderon observed the facility infection control practices. LPA Calderon observed screening protocols for visitors, staff, and residents, sanitizing stations (Located in common areas and restrooms). LPA Calderon observed staff and residents were NOT wearing face coverings, an isolation room and required postings throughout the facility. LPA Calderon observed the facility has a thirty-day (30) supply of Personal Protective Equipment (PPE). LPA Calderon advised the Administrator Rommel Dungca to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon did not observe any deficiencies therefore NO citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Staff Cesar Tuazon.the state’s words, verbatim · CDSS document, Dec 6, 2023