197602434-1-27-2023-29-AS-JAPL-CNLRQM-20230131121346

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197602434
Report Date: 01/27/2023
Date Signed: 01/27/2023 03:33:53 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
04/22/2022 and conducted by Evaluator Elsie Campos

COMPLAINT CONTROL NUMBER: 29-AS-20220422093102

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:	01/27/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Dion D Gallarza		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Due to lack of care and supervision resident was verbally abused by another resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elsie Campos arrived unannounced for a subsequent complaint investigation. The LPA met with Executive Director Dion Gallarza and explained the reason for the visit.

On 4/28/2022, LPA Ashley Smith obtained documents, interviewed staff at 9:19 a.m., 9:40 a.m., 9:50 a.m., and 9:54 a.m.; and interviewed residents at 10:03 a.m., 10:34 a.m., 10:57 a.m., and 11:08 a.m. During today's visit, the LPA interviewed staff at 10:00 a.m. and toured the facility at 10:15 a.m.

Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

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-20220422093102

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: 01/27/2023

NARRATIVE

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Regarding the allegation: Due to lack of care and supervision resident was verbally abused by another resident.

The complainant alleged that a resident was being verbally abused by another resident. To investigate, the LPA conducted interviews with residents and staff. Interviews revealed that the residents have a history of picking fights with one another however it is not due to a lack of care and supervision. Resident #1 (R1) indicated that although they tried to establish a friendship with Resident #2 (R2) they just did not click. R1 stated that they only wanted to be left alone and denied claims that R2 was ever physically assaultive and began to avoid the dining room to stay away from R2. R2 expressed that R1 now sits with a group of residents that R2 used to sit with and were friends with. R2 indicated that they believe R1 did not want them to have any friends. Interviews with residents revealed that R1 and R2 do not agree on common issues such as seating arrangements in the dining room. Residents denied claims that R2 was verbally abusive. Residents further expressed positive experiences at this facility and denied otherwise overhearing, observing, or experiencing any verbal abuse from residents.

Based on the information obtained, there is insufficient evidence to support the claim that due to lack of care and supervision resident was verbally abused by another resident. This allegation is deemed Unsubstantiated at this time.

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

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

LIC9099 (FAS) - (06/04)

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