197602434-4-7-2023-29-AS-JAPL-CRC2T3-20230428174005

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197602434
Report Date: 04/07/2023
Date Signed: 04/07/2023 03:46:35 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
06/01/2022 and conducted by Evaluator Elsie Campos

COMPLAINT CONTROL NUMBER: 29-AS-20220601142537

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: 100	DATE:	04/07/2023
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Buisness Office Manager Katia Arriaga		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff handled resident in a rough manner resulting in injury

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elsie Campos arrived unannounced for a subsequent complaint visit to deliver the findings on the above allegation. The LPA met with Buisness Office Manager Katia Arriaga and explained the reason for the visit.

On 6/6/2022, LPA Salia Walker conducted a physical plant tour with Administrator Dion Gallarza at 9:58 a.m. From 10:07 a.m. until 10:20 a.m., the LPA conducted an interview with facility staff. From 10:22 a.m. until 10:25 a.m., the LPA conducted an interview with the complainant. On 2/15/2023 LPA Campos spoke with Administrator Dion Gallarza, collected documents and reviewed police report at 11:00 a.m., conducted interviews with facility staff at 2:20 p.m. and 3:30 p.m.

**Continued on LIC 9099-C**

Substantiated

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: 04/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023

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 4

Control Number 29-AS-20220601142537

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: 04/07/2023

NARRATIVE

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Regarding the allegation: Staff handled resident in rough manner resulting in injury.

Concerns were that a facility staff handled a resident in a rough manner resulting in injury. It was alleged that resident #1 (R1) was pushed to the ground by staff #1 (S1). Witness to the incident, Staff #2 (S2), indicated that as they were approaching R1’s room and they could hear that R1 and S1 were arguing. S2 observed that S1 was blocking R1 from exiting their room as R1 was allegedly trying to leave their room to look for their family member. R1’s family member was not present in the facility; this urge was generated by R1’s dementia. The resident became agitated and reportedly pushed S1 and then S1 became agitated with R1 and subsequently pushed them, resulting in R1 falling to the ground. As a result of the fall, R1 sustained a minor cut above the corner of their left eye.

R1 has dementia, refused to be interviewed by LPA Walker and had no memory of the incident based on other interviews. Interviews revealed that Staff #3 (S3) arrived to help S2 after S1 had pushed R1, resulting in a fall. S3 stayed with R1 until paramedics arrived while S2 went to get the in touch with the Administrator.

The Administrator contacted the police on the day of the incident, the police report indicated that R1 was upset due to a Dementia episode and pushed S1. S1 became upset and grabbed R1’s right arm and pushed R1 to the ground causing their head to bleed. Paramedics arrived and administered First Aid to R1 at the facility. The paramedics cleared R1 to remain at the facility as per R1’s request.

Interviews with S2 confirmed that S1 had pushed R1 to the ground. S2 stated that when they asked S1 ‘why did you do that?, S1 denied that they knew what happened. The LPA’s interview with S1 did not confirm or deny the above allegation as they stated that they did not recall the incident. The Administrator conducted an investigation into the incident and indicated that S1 had recognized that R1 had fallen but claimed their mind had gone blank and did not provide further explanation to the administrator. The administrator further explained that S1 did not defend themselves against the allegation or say it was an accident and only continued to claim that their mind went blank.

**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: 04/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220601142537

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: 04/07/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/11/2023 Section Cited HSC 1569.269	1 2 3 4 5 6 7	1569.269 Enumerated rights; severability (a)(10) Residents of residential care facilities for the elderly shall have all of the following rights: To be free from ... verbal, mental, physical, or sexual abuse.This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The administrator agreed to the following: To provide a scheduled date for staff in-service regarding regulation 1569.269(a)(10) to CCL by 4/11/23. Administrator will provide documentation of staff in-service to CCL by 4/21/23.
	8 9 10 11 12 13 14	Based on interviews, the licensee did not comply with the section cited above as the resident was handled roughly by staff resulting in an injury which poses an immediate health, safety and personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220601142537

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: 04/07/2023

NARRATIVE

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The administrators interview with S2 explains that S2 confirmed that they saw S1 shove R1. The Administrator interviewed R1; however, R1 was unable to recall the incident as they were diagnosed with Dementia. The LPA’s interview with the Administrator Dion Gallarza confirmed that S1 was sent home, suspended, pending an investigation, and ultimately terminated from their position with the belief that they did violate company policy 4.2 Standards of Conduct and 8.4 Policy against workplace violence by pushing R1 back after being pushed by R1, which resulted in R1 sustaining a fall.

Based on the information obtained during the course of the investigation and interview conducted, it was confirmed that staff #1 (S1) did handle the resident roughly which resulted in an injury. Therefore, the allegation is deemed Substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D):

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023

LIC9099 (FAS) - (06/04)

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