197602434-1-31-2023-29-AS-JAPL-CNU2H8-20230207162418

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197602434
Report Date: 01/31/2023
Date Signed: 01/31/2023 02:41:13 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
05/11/2022 and conducted by Evaluator Elsie Campos

COMPLAINT CONTROL NUMBER: 29-AS-20220511104201

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: 96	DATE:	01/31/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Dion D Gallarza		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Facility staff do not intervene in resident on resident verbal altercations
Financial abuse

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 5/16/2022, LPA Salia Walker conducted a physical plant tour, obtained documents pertinent to the investigation, interviewed staff at 1:20 p.m., and 3:00 p.m., interviewed the Administrator at 2:00 p.m.; and interviewed resident(s) at 3:26 p.m. On 1/27/2023, the LPA interviewed staff at 10:00 a.m., toured the facility at 10:15 a.m., interviewed residents at 2:22 p.m., 2:27 p.m. and 2:30 p.m. During today’s visit the LPA interviewed residents at 10:57 a.m. and staff at 11:11 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: 01/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

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-20220511104201

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: 01/31/2023

NARRATIVE

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Regarding the allegation: Facility staff do not intervene in resident on resident verbal altercations

On the allegation, “Facility staff do not intervene in resident on resident verbal altercations.” – The complainant alleged that Resident #1 (R1) is always screaming and yelling at Resident #2 (R2) for sitting in their place in the dining room and further alleged that staff do not want to do anything about it. Interviews with staff reveled that R1 and R2 have a history of disagreements with one another, which centers around seating in the dining room. R2 denied claims that R1 was ever physically assaultive and began to avoid the dining room to stay away from R1. 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 the lack of response from staff. Information obtained through other resident interviews found that if residents argue staff intervene when needed. Staff noted that in order to mitigate concerns between R1 and R2, staff will talk to the involved parties and de-escalate the situation at the time if required. The administrator further confirmed that an investigation is conducted with parties involved to find resolution amongst residents who are in the disagreement.

Based on the information obtained, there is insufficient evidence to support the claim that facility staff do not intervene in resident on resident verbal altercations. This allegation is deemed Unsubstantiated at this time.

Continued on LIC 9099-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220511104201

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: 01/31/2023

NARRATIVE

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Regarding the allegation: Financial abuse

On the allegation, “Financial abuse.” – The complainant alleged that Resident #2 (R2) was charged $100 for tray service for the month of March 2022 which they were not in need of. R2 stated that they were told that they would be provided with tray service at no charge if they could not go to the dining room. Interviews with R2 revealed that they were not feeling well and had requested tray service but were told they would not be charged. Interviews with staff denied claims that R2 would not be charged. The facility will waive a tray passing charge if the resident is in fact sick or unable to go to dining room for medical reasons. Interviews with staff revealed that R2 was credited back five (5) tray passing services for the month of March 2022 and charged for the remainder of the services as R2 simply did not want to go to the dining room to avoid another resident. Staff confirmed that a conversation was had with R2 to clarify the discrepancy. A record review confirmed that R2 was tray passed fifteen (15) times in the month of March and charged for ten (10) instances. The complainant further alleged that R2 was told that the administration of medication would be three hundred ($300) a month but is being billed four hundred ($400) a month. A record review revealed that R2 had signed an agreement agreeing to the administration of medication being billed at four hundred and eleven dollars ($411) a month.

Based on the information obtained, there is insufficient evidence to support the claim of financial abuse. 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: 01/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

LIC9099 (FAS) - (06/04)

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