195850334-2-16-2024-29-AS-BBAI-D2HUHT-20240216143629

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850334
Report Date: 02/16/2024
Date Signed: 02/16/2024 02:37:50 PM

Document Has Been Signed on 02/16/2024 02:37 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: 5	DATE:	02/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Alla Harutunyan		TIME COMPLETED:	03:00 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 arrived at the facility unannounced to conduct a required annual inspection. Upon arrival LPA met with Administrator Alla Harutunyan and explained the reason for the visit. At approximately 10:45am, 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. The carbon monoxide and smoke alarms were tested and all functioned properly. The fire extinguisher was fully charged and last serviced in June 09, 2023. The kitchen appeared to be clean and the appliances and fixtures functional. LPA observed a sufficient amount of perishable food stored in the fridge and non-perishable food properly stored. Kitchen knives are stored in a locked drawer in the center island of the kitchen. Stove burners are rendered inaccessible to the residents by installing a lock when not in use. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0F) and the refrigerator was maintained at 40F. 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. 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. All rooms were free of odors. All window screens were clean and maintained in good repair.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024

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 3

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: 02/16/2024

NARRATIVE

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Continued from 809

Common Areas: These included the living rooms and dining areas. The common areas were properly furnished and appeared to be relatively clean at this time.

The exterior passageways were clean and clear of any obstructions. There is a covered patio area 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 self-latching mechanism for persons to enter the back yard. 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 resident. LPA observed the garage to store, Personal Protective Equipment, incontinent supplies, toiletries and other materials and equipment for facility use

Records review began at 11:00am, five (5) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Two (2) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were observed to be in order at this time. Last emergency / disaster drill was conducted on 01/15/2024.

During today’s visit, LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station. LPA observed 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 a communicable disease. The facility has not had a confirmed case of a communicable disease at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate at this time.

Medications review began at approximately 1:30pm The medications are centrally stored in a locked cabinet in the dining area inaccessible to residents in care. Medications were observed to be properly documented on the centrally stored medications and destruction record at this time

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: 02/16/2024

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 26 27 28 29 30 31 32	Continued from 809-C LPA interviewed three (3) residents and Administrator during the visit. LPA obtained the following documents - Census, Staff schedule, and Limited Liability insurance. Exit interview conducted and a copy of report was was provided

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3