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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850161
Report Date: 05/24/2021
Date Signed: 05/24/2021 01:59:18 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:LAKE BALBOA RESIDENTIAL CAREFACILITY NUMBER:
195850161
ADMINISTRATOR:TERZYAN, SEROBFACILITY TYPE:
740
ADDRESS:7647 PASO ROBLES AVETELEPHONE:
(818) 439-8482
CITY:LAKE BALBOASTATE: CAZIP CODE:
91406
CAPACITY:6CENSUS: 3DATE:
05/24/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Serob Terzyan - LIcensee TIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Brian Balisi made an Announced Pre licensing visit to the above facility. Upon arrival, LPA met with Licensee Serob Terzyanr and explained the reason for the visit. This is a change of ownership as this address previously operated as Lake Balboa Board & Care Inc #197609114

At 11:30am, A tour of the physical plant was conducted with Licensee. LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. The following was noted:

Facility is a single story residential home with four (4) bedrooms and three (3) bathrooms. There is an additional room designated for staff use. Facility has dementia residents. All exit signal alarms were tested and function properly. Smoke detectors and Carbon Monoxide detector were tested and functioned properly during time of visit. Fire extinguisher was observed to be fully charged and last serviced in January 2021.

Kitchen: The kitchen appeared clean and the appliances and fixtures functional at this time. LPA observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects are stored in a locked drawer in the island in the middle of the kitchen. Bedrooms: The resident bedrooms were properly furnished with at least one chair, night stand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Bathrooms: LPA observed all bathrooms were clean, properly supplied and had functional fixtures. LPA observed grab bars and non-skid mats in all bathrooms. Residents have sufficient amounts of supplies for personal hygiene. The hot water was measured in each bathroom during physical plant tour. Hot water measured between 111-116 degrees Fahrenheit in all bathrooms during visit.

Continued on LIC809-C..
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021
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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: LAKE BALBOA RESIDENTIAL CARE
FACILITY NUMBER: 195850161
VISIT DATE: 05/24/2021
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Continued from 809

Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Medication is stored in a locked cabinet in the hallway. At 11:50am, LPA observed residents watching television. Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use. There was also a garage in the rear of the facility used to store furniture, medical supplies, and extra refrigerators to store food for staff.


Between 12:30pm - 1:30pm Component III was conducted in conjunction with the visit.


Exit Interview Conducted / A Copy of the Report Issued via E-mail.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021
LIC809 (FAS) - (06/04)
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