197602434-3-27-2023-29-AS-JAPL-CQDTTH-20230329150047

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197602434
Report Date: 03/27/2023
Date Signed: 03/27/2023 03:27:57 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
01/23/2023 and conducted by Evaluator Angel Ascencio

COMPLAINT CONTROL NUMBER: 29-AS-20230123092638

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: 98	DATE:	03/27/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Dion Gallarza		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Staff failed to prevent resident from being bullied by another resident
Staff failed to provide a safe and comfortable environment for resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent visit to deliver findings to the above facility. LPA Ascencio met with Executive Director (ED) Dion Gallarza at 10:40 a.m. Entrance interview conducted.

On 01/23/2023, the Department received a complaint alleging that staff failed to prevent from being bullied, and staff failed to provide a safe and comfortable environment for resident. On 01/27/2023, LPA Ascencio met with Executive Director (ED) Dion Gallarza at 12:32 p.m. Interview with ED Gallarza revealed that Resident #1 (R1) and R2 had a verbal altercation during breakfast on 01/21/2023. R1 was sitting at a dining room table, were R2 normally sits. Around 7:00 a.m., R2 walked into the dinning screaming and yelling at R1 after observing R1 at the table. ED Gallarza stated that there is open seating at the dining room, but R2 is adamant on sitting at this table. R1 and R2, at one point in time were friends, then it changed.

Continued on LIC 9099 - C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

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-20230123092638

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: 03/27/2023

NARRATIVE

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ED Gallarza added that they obtained reports of the altercation from a kitchen staff and Activity Director who stepped in to stop R1 and R2. ED Gallarza lastly added that they spoke to R1 and R2 separate and re-iterated the importance of code of conduct from resident and the facility house rules. ED Gallarza said they have tried to keep R1 and R2 apart during meals, and activities but it is a difficult challenge if both want to attend the same event. Staff are aware of the situation between them and if in the same room, staff are instructed to seat residents at opposite sides of room. Although resident have the right to attend any event within the facility, staff are fully aware of the history between R1 and R2 if both are in an activity, thus with staff knowledge, it minimizes the opportunity of residents being bullied.

That same day, interview with Staff #1(S1) at 1:25 p.m. and S2 at 2:00 p.m., confirmed what ED Gallarza stated. Interviews with staff revealed that they observed R2 walk up to R1 and started to yell during breakfast. S1 stated they walked between the R1 and R2 and told them to stop yelling as the dining room is open seating. S2 added that R2 was yelling while R1 sat there at the table. Staff stated that after intervening, R2 stopped yelling, and sat at the opposite side of the dining with no further incident. Later that same day, interview with R2 at 2:30 p.m., confirmed what ED Gallarza and staff stated. Additionally, R2 added that they do not recall what was said, but R2 confirmed that they yelled at R1 for sitting at this table. R2 lastly added that a staff and another resident intervened and walked R2 out of the dining room. Even though R2 presented with behaviors during the morning mealtime, staff was quick to respond and intervene to provide a safe environment for all residents in the dinning room.

Interview with R1, on 03/14/2023 at 1:50 p.m., confirmed what was previously stated by the ED, staff and R2. Lastly, R1 added that staff have been doing a great job separating both residents to prevent any future altercations. Staff interviews on 03/27/2023, starting at 12:30 p.m., revealed that staff are helpful and due their diligence to provide the best care possible for resident. Additionally, they have not heard of any staff yelling at residents. Lastly, staff communicated the procedure if there were to be any verbal or physical altercations between the residents. That same day, resident interviews, starting at 12:37 p.m. revealed that the staff are very nice and helpful. Additionally, staff have not yelled, or been disrespectful in any way toward any resident. Lastly, resident interviews added that do not feel bullied or intimidated, but instead, feel safe and comfortable living at this facility.

Continued on LIC 9099 - C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230123092638

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: 03/27/2023

NARRATIVE

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The Department acknowledges the staff are unable to be present during all incidents, as R1 and R2 do not require 1:1 supervision. Yet, when staff were alerted to the disagreement between R1 and R2, staff appropriately intervened with the intention of creating a safe environment for all residents, including R1 and R2. Staff and resident interviews supported claims that resident felt safe and supported while residing in this community. Residents feel that if disagreements occur, staff appropriately intervene and prevent other residents and or other parties from feeling intimidated or bullied. Based on evidence gathered throughout the investigation, there is insufficient evidence to support the claims of staff failed to prevent resident from being bullied and staff failed to provide a safe and comfortable environment for residents. Thus, the allegations are deemed Unsubstantiated at this time.

Exit interview conducted and copy of the report was issued to ED.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

LIC9099 (FAS) - (06/04)

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