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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602434
Report Date: 11/22/2022
Date Signed: 11/22/2022 12:53:51 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/04/2022 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20221104114834
FACILITY NAME:GARDENS AT PARK BALBOA, THEFACILITY NUMBER:
197602434
ADMINISTRATOR:DION D GALLARZAFACILITY TYPE:
740
ADDRESS:7046 KESTER AVENUETELEPHONE:
(818) 787-0462
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY:120CENSUS: 94DATE:
11/22/2022
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Dion GallarzaTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff failed to treat resident with dignity and respect
Licensee is not assisting resident with arranging transportation for medical care
Grab bars not placed appropriately
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to issue findings for the above allegations. The LPA met with Executive Director Dion Gallarza and explained the reason for the visit.

On 11/7/2022, the LPA and the Executive Director toured the facility from 10:30 a.m. – 12:00 p.m. During the tour, the LPA and the Executive Director entered thirteen (13) randomly selected rooms and inspected the installed grab bars, tested the wall pendants, and checked the water temperature. In addition, the LPA interviewed seven (7) residents from 10:30 a.m. – 12:00 p.m. The LPA also reviewed documents pertinent to the investigation, and conducted staff interviews at 9:42 a.m. and 11:00 a.m. The LPA spoke with Resident #1 (R1) on 11/7/2022 at 3:55 p.m. and on 11/22/2022 at 11:25 a.m.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 29-AS-20221104114834
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/22/2022
NARRATIVE
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Regarding the allegation: Staff failed to treat resident with dignity and respect

It was alleged that staff were disrespectful to Resident #1 (R1). Interviews confirmed that there had been interactions between staff and R1, in which R1 felt that they were accused of lying. Staff said that they had attempted to clarify situations with R1, but staff denied claims that they had ever accused R1 of lying and said they never called R1 a ‘liar’. Staff claimed that in discussion with R1, staff has attempted to clarify situations and provide additional context yet did not perceive their interactions as disrespectful. Staff denied ever cutting R1 off or speaking to R1 in a rude tone.

Information obtained from interviews revealed that residents felt that staff were respectful in their approach and denied claims of ever feeling disrespected by the staff. Residents did not have any negative things to say about the staff. Based on the information obtained, there is insufficient evidence to support the claim that staff failed to treat resident with dignity and respect. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Licensee is not assisting resident with arranging transportation for medical care.

It was alleged that staff failed to assist the resident with arranging transportation for medical care. The Executive Director confirmed that if there are changes to the transportation schedule or the availability, they will send out a memo to the residents. The Executive Director communicated that in the event that there is an issue with the facility provided transportation, they will assist residents with securing transportation from a third party, or in some cases, they will arrange transportation for residents free of charge. During the tour, the LPA observed that the transportation notices are posted on the bulletin board in the front hallway. An interview with Resident #1 (R1) confirmed that R1 believed the transportation schedule was not conducive to residents with multiple doctor’s appointments and personal appointments. However, interviews with residents confirmed that they are aware of the transportation protocol and have communicated no issues with utilizing the transportation provided by the facility. Residents interviewed stated that they are aware that for the most part, appointments to use transportation must be scheduled in advance.

Based on the information obtained, there is insufficient evidence to support the claim that the licensee failed to assist the resident with arranging transportation for medical care. This allegation is deemed Unsubstantiated at this time.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20221104114834
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/22/2022
NARRATIVE
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Regarding the allegation: Grab bars not placed appropriately.

It was alleged that the grab bars in R1’s room were not appropriately placed. Interviews confirmed that the resident bathrooms are equipped with two grab bars in the shower. Interviews confirmed that at the request of the resident, the facility will install additional grab bars per their preference. Staff claimed that consistent conversation was had with R1 regarding where R1 wanted the grab bars to be placed. Per the request, the facility installed three (3) additional grab bars. However, R1 did not like the width of the newly installed bars and requested three (3) new grab bars to replace the ones that were installed. Conflicting information was shared regarding the installation of the grab bars; whereas staff claimed that they attempted to accommodate R1’s specifications, R1 felt that the staff failed to follow R1’s instructions to ensure proper placement. The LPA reviewed a document entitled ‘Grab Bar Modification’, in which the facility documented their efforts in accommodating R1’s request for additional grab bars and documented the specifications of the newly placed grab bars. This document was signed by both the Executive Director and R1 and was dated 10/17/2022. Although R1 is moving into a new room in the coming weeks, the staff agreed to install additional grab bars in R1’s new room per R1’s request. During the LPA’s tour on 11/07/2022, the LPA observed that grab bars were placed in the shower/bathtub unit. Staff claimed they were placed per the direction of R1. Each grab bar observed appeared to be in good condition and securely fastened.

Based on the information obtained, there is insufficient evidence to support the claim that grab bars were not appropriately placed. At R1’s request for additional grab bars, the facility accommodated. Per Title 22 Regulations, the grab bars in the resident showering unit shall be appropriately placed. This allegation is deemed Unsubstantiated at this time.

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

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3