197602434-11-7-2022-29-AS-JAPL-CLMU64-20221129141742

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197602434
Report Date: 11/07/2022
Date Signed: 11/07/2022 04:14:17 PM

Substantiated

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, 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: 94	DATE:	11/07/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Dion Gallarza		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Call buttons not working
Water temperature not within required range.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for an initial 10-day complaint visit. The LPA met with Executive Director Dion Gallarza and explained the reason for the visit.

During today’s visit, 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 fourteen (14) 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.

CONT 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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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: 11/07/2022

NARRATIVE

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Regarding the allegation: Call buttons not working

It was alleged that Resident #1’s call button was not working. Interviews confirmed that Resident #1 (R1) suffered a fall on 11/03/2022, in which S1 and S2 responded to the incident. Interviews noted that R1 had pressed their call button on the wall, yet upon pressing it, discovered it was not working. Interviews with S1 and S2 confirmed that they observed that R1’s call button on the wall was not working and attempted to fix it in the moment. The LPA checked the call button on the wall in R1's bathroom at 11:55 a.m. and it was operable at the time of observation.

During today’s physical plant tour, the LPA and Executive Director identified that Rooms 100, 104, and 260 did not have a call button installed in the unit. It was communicated that it was possible that the call buttons in those rooms were being repaired or checked. Based on the information obtained from observations and interviews, there is sufficient evidence to support the claim that the call buttons were not working. This allegation is deemed Substantiated at this time.

Regarding the allegation: Water temperature not within required range

It was alleged that the water temperature was registering above 120 degrees Fahrenheit, which is outside of the range per regulation. During today’s physical plant tour, the LPA and Executive Director identified that the water temperature registered above 120 degrees Fahrenheit in rooms 104, 122, 126, and Room 212, which is R1’s room. Based on the information obtained from observations and interviews, there is sufficient evidence to support the claim that the water temperature was not within the required range as per regulation. This allegation is deemed Substantiated at this time.

Pursuant to the California Code of Regulations, Title 22, Division 6, the following deficiency was observed and cited during the visit. See LIC 9099-D.

Exit interview conducted. Appeal rights discussed. Copy of report issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022

LIC9099 (FAS) - (06/04)

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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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/07/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/09/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator has agreed to do the following: 1. Check all signal units in each resident room to ensure the signal unit is operational. Inform CCL when this has been completed, but no later than 11/09/2022, end of day.
	8 9 10 11 12 13 14	Based on interview and observation, the licensee did not comply with the section cited above, as R1's call button was inoperable on 11/3/2022 and 3 out of 14 rooms did not have a call button in the resident unit, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type A 11/08/2022 Section Cited CCR 87303(e)(2)	1 2 3 4 5 6 7	87303(e)(2) Maintenance and Operation. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F and not more than 120 degree F. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator has agreed to do the following: 1. Adjust the water boilers within the next 24 hours. 2. Conduct a 3 day water temperature log for ten rooms spread throughout the facility. Include rooms 104, 122, 126, and 212.
	8 9 10 11 12 13 14	Based on observation, the licensee did not comply with the section cited above, as water temperature measured above 120 degree F in four (4) out of fourteen (14) rooms, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	Submit log no later than 7/16/2022.

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022

LIC9099 (FAS) - (06/04)

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