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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850161
Report Date: 11/09/2021
Date Signed: 11/09/2021 05:45:08 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: 5DATE:
11/09/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Serob TerzyanTIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Brian Balisi and JoAnn Rosales conducted an unannounced Post Licensing Visit. LPAs met with Administrator Serob Terzyan.

Today's evaluation included but was not limited to building and grounds, resident rooms, bathrooms, hot water temperature (read at 105 degrees F.) in resident bathroom, common areas, personal accommodations, food and first aid supplies. LPAs observed lamps/lights for each room. LPAs observed fire extinguishers fully charged. Centrally stored medicines are kept in a locked hallway closet. Hygiene items are being provided. Grab bars and non-skid materials were present in the bathrooms. LPAs observed facility temperature at 69 degrees. Smoke alarms and carbon monoxide detectors were tested and operable. Outdoor area toured- passageways are free of obstruction. LPAs observed disaster drills being conducted. Last drill was conducted 10/20/2021. LPAs reviewed a sampling of resident records and medications. LPAs reviewed a sampling of staff records.

During facility tour at 11:10am with Staff Nelli Ghevenyan , LPAs observed wound cleanser in Resident 1 (R1) and R2 bedroom accessible to residents.

During facility tour at 11:12am, with Staff, LPAs observed no rinse shampoo, air freshener, no rinse cleanser, toothpaste, and toilet bowl cleaner in Bathroom #2 accessible to residents.

During facility tour at 11:17am, with Staff Helen , LPAs observed cologne, in unlocked staff room accessible to residents.

During facility tour at 11:20am, with Staff Helen, LPAs observed Humalog insulin, Lantus insulin, Calcitonin nasal spray, Humulin, Lantus pen, in an unlocked box in kitchen refrigerator
Continued on 809-C
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 7
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: 11/09/2021
NARRATIVE
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During a review of R1s medications starting at 2:17pm, with staff Helen, LPAs observed that Metaphormin was prescribed as 1 tablet every morning , but it is being given twice a day.

During a review of R1s medications starting at 2:50pm, with staff Helen, LPAs observed R1 is being given gas and bloating prevention capsules 3 times a day without a physicians order. Staff stated they did not have a physicians order on file.

During a review of R1s medications starting at 2:54pm, with staff Helen, LPAs observed R1 is being given Omeprazole capsules 1 time a day without a physicians order. Staff stated they did not have a physicians order on file.

During a review of R1s medications starting at 2:57pm, with staff Helen, LPAs observed R1 is being given Senna tablets 1 time a day without a physicians order. Staff stated they did not have a physicians order on file.

During a review of R1s medications starting at 2:59pm, with staff Helen LPAs observed R1 is being given expired Calcium 600mg tablets 1 time a day. Physicians order was prescribed for 500mg 1 tablet two times a day.

During a review of R1s medications starting at 3:01pm, with staff Helen, LPAs observed R1 is being given Fiber and Papaya enzyme, magnesium, probiotic and Antacid tablets without physicians orders. Staff stated they did not have physicians orders on file.

During a review of R3s medications starting at 3:13pm, with staff Helen, LPAs observed R3 is being given Dicyclomine 1 capsule a day. Physicians order was prescribed at 1 capsule 4 times a day.


Continued on 809-C
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
LIC809 (FAS) - (06/04)
Page: 3 of 7
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/19/2021
Section Cited

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87705 Care of Persons with Dementia(f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication...cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
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Based on LPA's observations and record review, the licensee did not comply with the section cited above as toxic substances were observed accessible to residents which posed an immediate health risk to persons in care.
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Type A
11/19/2021
Section Cited

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87465 Incidental Medical and Dental Care Services (h)(2) Centrally stored medicines shall be kept in a safe and locked place... employees responsible for the supervision of the centrally stored medication.
This requiremtn is not met as evidenced by:
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Based on LPA's observation, the licensee did not comply with the section cited above as resident medications were accessible to residents which posed an immediate health risk to persons in care
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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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2021
LIC809 (FAS) - (06/04)
Page: 2 of 7
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/10/2021
Section Cited

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87465 Incidental Medical and Dental Care Services (a)(5) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
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Based on interviews and record review, the licensee did not comply with the section cited above in 2 out of 5 resident medications which poses an immediate health risk to persons in care.
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Type A
11/10/2021
Section Cited

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87465 Incidental Medical and Dental Care Services (e) For every prescription and nonprescription... Both the physician's order and the label shall contain at least all of the following information.
This requirement is not met as evidence by:
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Based on interviews and record review, the licensee did not comply with the section cited above in 2 out of 5 resident medications which poses an immediate health risk to persons in care.
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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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2021
LIC809 (FAS) - (06/04)
Page: 5 of 7
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: 11/09/2021
NARRATIVE
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During a review of first aid kit at 3:21pm, with staff Helen, LPAs did not observe First aid manual.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted. Today's reports and appeal rights were reviewed and emailed to the Administrator.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
LIC809 (FAS) - (06/04)
Page: 7 of 7
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/10/2021
Section Cited

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87465 Incidental Medical and dental care (h)(4) All centrall stored medications shall be labeled... No persons other than the dispensing pharmacist shall alter a a prescription label.
This requirment was not met as evidenced by:
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Based on interviews and record review, the licensee did not comply with the section cited above in 1 out of 5 resident medications which poses an immediate health risk to persons in care.
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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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2021
LIC809 (FAS) - (06/04)
Page: 4 of 7
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/19/2021
Section Cited

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87465 Incidental Medical and Dental Care (a)(9)(A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency.

This requirement is not met as evidenced by:
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Based on LPA's observations, the licensee did not comply with the section cited above as there is not a current edition of a first aid manual, which poses a potential safety risk to persons in care.
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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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2021
LIC809 (FAS) - (06/04)
Page: 6 of 7