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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602434
Report Date: 09/28/2023
Date Signed: 09/28/2023 04:38:26 PM


Document Has Been Signed on 09/28/2023 04:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:GARDENS AT PARK BALBOA, THEFACILITY NUMBER:
197602434
ADMINISTRATOR:DION D GALLARZAFACILITY TYPE:
740
ADDRESS:7046 KESTER AVENUETELEPHONE:
(818) 787-0462
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY:120CENSUS: 98DATE:
09/28/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Dion D. Gallarza, AdministratorTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst(LPA) Christine Yee conducted an unannounced subsequent required Annual Inspection to continue the annual inspection that was initiated on 9/27/23. The complete CARE Inspection Tool was used and the visit was conducted with Dion Gallarza, Administrator. The reason for the return visit was explained.

On today's visit the following domains were reviewed: Personnel Records Training, Resident Rec-Incident Reports, Resident Rights Information, Planned Activities, Food Service, Incidental M &D, Disaster Preparedness and Residents with SHN. Due to time constraints, LPA Yee was not able to review the Physical Plant and Environmental Safety Domain. A return visit will have to be conducted to complete the last domain.

Facility files, training records, 10 resident files and the Emergency Disaster Plan were also reviewed during today's visit. Per review of the information requested for in each domain reviewed, there were no deficiencies observed.

On today's visit, LPA Yee also delivered the Immediate Civil Penalties that were assessed for the deficiency cited as a result of the substantiated findings for complaint #29-AS-20220601142537 on 4/7/23.

No deficiencies were cited on today's visit.

Exit interview was conducted and a copy of this report was provided
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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