195850334-2-9-2023-29-AS-BBAI-CNVS6M-20230209123609

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850334
Report Date: 02/09/2023
Date Signed: 02/09/2023 12:36:25 PM

Document Has Been Signed on 02/09/2023 12:36 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BALBOA ASSISTED LIVING INC		FACILITY NUMBER:	195850334
ADMINISTRATOR:	HARUTUNYAN, ALLA		FACILITY TYPE:	740
ADDRESS:	7647 PASO ROBLES AVE		TELEPHONE:	(818) 434-9916
CITY:	LAKE BALBOA	STATE: CA	ZIP CODE:	91406
CAPACITY:	6	CENSUS: 4	DATE:	02/09/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Alla Harutunyan		TIME COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Brian Balisi conducted a pre-licensing visit to the above noted facility. The LPA met with applicant, Alla Harutunyan. This application is a change of ownership. The home is currently licensed as Lake Balboa Residential Care #195850161. A dementia program was included in the plan of operation. Hospice Waiver has been requested for (2) residents. The facility is one story. At 10am, a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for (5) non-ambulatory residents; and, (1) of bedridden resident. The facility has (4) private resident bedrooms approved for Non- Ambulatory residents, Rooms #3 is also approved for (1) bed ridden resident. Resident rooms #2 and #3 have direct exits to the outside. All resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. Room # 5 is a designated staff room, LPA observed it to be empty at this time. All rooms were free of odors. All window screens were clean and maintained in good repair. are 2 bathrooms in the hallway and 1 bathroom in room #3. The resident bathroom(s) have a shower with non-skid materials. The toilet and shower have grab bars. The hot water temperature was tested in the bathrooms and the kitchen and was found to be within the range of 113F and 117F. Resident and staff records are stored in a locked closet located near bedroom #2. Medications and first aid kit are centrally stored and inaccessible in this location as well. The first aid supplies were complete, including a thermometer and a current version of a first aid manual is stored in this closet as well.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

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: BALBOA ASSISTED LIVING INC	FACILITY NUMBER: 195850334
	VISIT DATE: 02/09/2023

NARRATIVE

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Kitchen knives are stored in a locked drawer in the center island of the kitchen. Stove burners are rendered inaccessible to the residents by removing them and placing in the locked drawer in the island. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F.   The supply of nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in the laundry area. This area was observed inaccessible to residents in care. No flies or other vermin were observed.

The common areas were appropriately furnished, and the lighting was adequate. There are televisions and other entertainment equipment, games and/or activity supplies in the living room. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to nonprivate bathrooms. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely.    There is no fireplace in the living room.   Alarms on all exterior doors were engaged at the time of visit and functional. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights, or other battery powered lighting, and batteries. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit.

The facility smoke alarm system is hard wired. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. There is a fire extinguisher located in the kitchen. LPA observed it to be fully charged and last service in March 2022. The laundry area is located next to the kitchen. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in a detached garage that was observed to be inaccessible to residents. Extra incontinence supplies are stored in this area as well.   There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted throughout the facility. The emergency telephone numbers are posted on bulletin board on entry way. Other required postings are posted at this wall as well.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

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: BALBOA ASSISTED LIVING INC	FACILITY NUMBER: 195850334
	VISIT DATE: 02/09/2023

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The exterior passageways were clean and clear of any obstructions. There is a covered patio area in the front and at the back of the house with tables and chairs where residents can sit. The entire property is not fenced. The back and sides of the house are separated from the front yard by gates at the east and west side passageways. There is a gate on the driveway. There is a door w/gate with a locking mechanism for persons to enter the back yard. Residents are able to easily exit from the gate in the event of an emergency. There are no other structures on the property. There are no bodies of water on the premises at the present time The garage is detached from the home and was inaccessible to residents. LPA observed the garage to store extra food, Personal Protective Equipment, incontinent supplies, toiletries and other materials and equipment for facility use.

Component III was completed in conjunction with the inspection.

Pre-Licensing is complete and this facility has no deficiencies. This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved

Exit interview conducted and report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

LIC809 (FAS) - (06/04)

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