197602434-8-26-2022-29-AS-ASMH-CHNRBC-20220826125232

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197602434
Report Date: 08/26/2022
Date Signed: 08/26/2022 12:52:52 PM

Document Has Been Signed on 08/26/2022 12:52 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:	GARDENS AT PARK BALBOA, THE		FACILITY NUMBER:	197602434
ADMINISTRATOR:	DION D GALLARZA		FACILITY TYPE:	740
ADDRESS:	7046 KESTER AVENUE		TELEPHONE:	(818) 787-0462
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY:	120	CENSUS: 86	DATE:	08/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Dion Gallarza		TIME COMPLETED:	12:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a required annual visit, which has an emphasis on infection control practices and procedures. The LPA met with Executive Dion Gallarza and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations.

Common Areas: The LPA toured the common spaces in the Assisted Living community and in the Safe Haven (Memory Care) community. Common areas were observed to be clean and in good condition. There were no obstructions and/or tripping hazards throughout the facility. The facility maintains a comfortable temperature at 75 degrees Fahrenheit. There are fire extinguishers throughout the community, which were fully charged. The Executive Director communicated that the fire extinguishers, generator, and sprinkler system would be inspected by an outside company in September 2022. Laundry room(s) were locked at the time of the visit.

Activities: Planned activities are offered. Activity schedule is posted throughout the facility. The LPA observed staff engaging with residents in the Assisted Living and Safe Haven (Memory Care) community.

Kitchen: The facility had a sufficient supply of two-day perishable and seven-day nonperishable food at the time of the visit. The facility uses Sysco and US Foods for food delivery. The menu was posted, and the facility offers an alternate menu.

Restrooms: Common restrooms were observed, and the LPA observed signs in the restrooms that promoted good hand hygiene. Restrooms were fully stocked with paper towels and soap. The LPA tested the water temperature in the common restroom on the first floor, which measured at 120.8 F.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

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: GARDENS AT PARK BALBOA, THE	FACILITY NUMBER: 197602434
	VISIT DATE: 08/26/2022

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Exterior Grounds: The LPA observed several courtyards throughout the community, which had adequate furniture with a covered shaded area for residents. No bodies of water noted at this time.

Infection Control: Throughout the visit, the LPA observed signs in common areas that promoted guidance around COVID-19, appropriate masking, physical distancing, and the disinfection protocol. Staff were observed wearing the appropriate face coverings. In addition, the LPA observed hand sanitizer interspersed throughout the common grounds. The community continues to monitor the vitals, symptomatic screening, and temperatures of the staff and visitors that come into the community. Staff are up to date regarding guidelines pertaining to visitation and vaccine requirements. The cleaning and sanitation protocol is adequate. The community is not experiencing any issues with staffing or obtaining Personal Protection Equipment (PPE) at this time. The LPA will submit a request for additional N95 masks and gloves.

The facility has previously managed COVID-19 active cases and the facility complied with all requirements set forth by the local health department and licensing. The community's policies and procedures as it pertains to infection control are adequate.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

LIC809 (FAS) - (06/04)

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