197602434-10-16-2023-29-AS-KHEN-D4TVR7-20240430163927

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197602434
Report Date: 10/16/2023
Date Signed: 10/16/2023 01:02:00 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
10/11/2023 and conducted by Evaluator Christine Yee

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20231011072146

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: 97	DATE:	10/16/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Katia Arriaga, Business Manager		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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1. Facility staff failed to provide timely access to resident's records

INVESTIGATION FINDINGS:

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LIcensing Program Analyst (LPA) Christine Yee conducted an unannounced complaint visit to investigate the above allegation and met with Katia Arriaga, Business Manager. Dion Gallarza was off today. The reason for today's visit was explained.

During today's visit, LPA Yee interviewed the Business Manager at 9:40am, the Administrator via telephone at 10:25am and Adam Khalifa, CEO at 10:56am regarding the request for documents for Resident #1.

Per complaint received, a formal request to provide a copy of Resident #1's records were faxed over to the facility on 10/6/23 by the legal representatives of Resident #1. Also included with the request were supporting authorization documents: a Declaration of Successor in Interest, a Authorization for Release of Medical Information signed by the next of kin and a copy of Resident #1'a death certificate was faxed over

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023

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-20231011072146

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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, THE	FACILITY NUMBER: 197602434
	VISIT DATE: 10/16/2023

NARRATIVE

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to the facility on 10/6/23. Attached to the complaint received, was a fax confirmation that the 8 page fax was successfully sent to the facility at 1:24pm with a connection time of 8.22 minutes. Per complainant, as of the filing date of this complaint, the legal representatives of Resident #1 have not been provided with the requested documents or have not been contacted by the facility to make arrangements to allow for the copying of the requested documents within the required time frame that is not to exceed 2 business days.

Per interviews conducted, with Katia Arriaga, Business Manager, the facility received a four page fax from the legal firm hired by the family to represent Resident #1 on 10/6/23. The four pages consisted of the fax cover, a blank page, a one page Declaration that the son was the beneficiary to Resident #1's estate and a copy of an illegible death certificate. The fax did not include a copy of the letter requesting Resident #1's file. The fax was given to the Administrator. Per review of the fax received, the fax cover indicates that the fax consisted of a 8 pages, which includes the fax cover. There is also a note on the fax cover that advises the recipient that if you do not receive the number of pages stated above or if re-transmission is necessary, to please contact the firm at the telephone numbers provided on the letterhead. No telephone call was made to obtain the missing pages not received on 10/6/23. Per the Administrator, contact with the legal representatives was not made until 10/12/23 to request a legible copy of the death certificate and he was advised that the death certificate would still be dark and illegible. The documents were requested to be emailed and was not received until 10/13/23. The documents were then forwarded to the corporate office for handling by the facility's attorney since the documents were related to a pending lawsuit against the facility. Per interview with the facility CEO, the request was not received until 10/13/23 and they are in the process of providing the documents. They did not refuse to provide the documents. LPA Yee and Katia advised the CEO that the request was originally faxed over on 10/6/23 and they had 2 days to make Resident #1's file available for copying. As of this visit, Resident #1's file has not been provided or made available to the legal representatives.

Based on the information received from interviews conducted on today's visit, the above allegation is substantiated.

Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8
Exit interview was conducted with Katia Arriaga, Appeals Rights discussed and a copy was given.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20231011072146

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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, THE	FACILITY NUMBER: 197602434
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/16/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/23/2023 Section Cited CCR 87468.2(a)(19)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Privately Operated Facilities: In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (19)To have prompt access	1 2 3 4 5 6 7	The Licensee will immediately contact the contact person noted on the request at the law firm to schedule a time when they may have access to Resident #1's file for copying. Licensee will provide a signed statement to Licensing stating the arrangements that have been made and agreed to by the facility and
	8 9 10 11 12 13 14	to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies. Facility failed to provide timely access to Resident #1's files	8 9 10 11 12 13 14	the legal representative to allow access to Resident #1's files by no later than POC date - 10/23/23,
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
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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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023

LIC9099 (FAS) - (06/04)

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