197602434-9-21-2024-29-AS-EMOY-D9C2R9-20240921173708

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197602434
Report Date: 09/21/2024
Date Signed: 09/21/2024 05:39:13 PM

Document Has Been Signed on 09/21/2024 05:39 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, 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: 102	DATE:	09/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Executive Director (ED), Dion Gallarza and Marketing Director, Jonathan McFall		TIME COMPLETED:	05:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Erica Mosley and Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at 9:00 a.m. Upon arrival LPAs were greeted by the front desk receptionist and explained the reason for the visit. Marketing Director Jonathan McFall arrived at approx. 9:40 a.m. and The Executive Director (ED) Dion Gallarza arrived during the inspection. LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: At approx 9:47 am, the LPA's began the physical plant tour, the furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. The fire extinguishers were fully charged and were last serviced 09/03/2024. The LPAs observed required postings throughout the common space. The LPAs observed the stairwells and they each had an emergency evacuation chair. Activity Rooms were observed and clean at the time of visit. Fireplaces were observed adequately screened. The LPA’s observed an adequate supply of emergency food and water. The last fire inspection was completed on 10/30/2023 and was found to be in compliance with Fire Code Regulations at the time of inspection. Emergency disaster drills conducted quarterly as per regulation; the last one conducted on 08/12/2024. The LPAs inspected the kitchen/food service area at 9:52 a.m. Knives are stored and inaccessible to residents. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. Continue on LIC809-C

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/21/2024

NARRATIVE

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CONTINUE FROM LIC 809

From approx. 10:01 a.m. to 10:45 a.m. The LPAs observed seven (7) randomly selected resident bedrooms, of which two (2) were in memory care and five (5) in assisted living which were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. The LPAs observed a sufficient supply of towels and linens.

The resident restrooms appeared clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared in the private rooms. The hot water measured between 107.9 – 119.6 degrees Fahrenheit all within the required range.

LPA’s reviewed Resident Records at approx. 10:40 a.m. Ten (10) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Ten (10) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. Daily vehicle inspection list and California Highway Patrol Inspection report was reviewed for facility vehicles. All records were in order.

During record review it was revealed that facility is approved for four (4) hospice residents however, the facility currently has five (5) residents on hospice. ED stated that their plan is to submit a hospice waiver increase.

Infection Control / Emergency disaster planning: During today’s visit the LPA’S reviewed the facility’s infection control practices and the facilities emergency disaster plan. The facilities policies and procedures as it pertains to infection control are adequate.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/21/2024

NARRATIVE

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CONTINUED FROM LIC 809-C
LPA’s conducted a medication review on four (4) randomly selected residents at approx. 02:00 pm, The medications are centrally stored in the medication room located in the memory care unit. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. At approx. 2:24 pm medication review revealed that three (3) out of four (4) PRN medications for Resident #1 (R1) have been administered however a record of each dose has not been document on the resident’s record. Additionally at approximately 3:05 pm medication review reveal that Resident #2 (R2) medication ROSUVASTATIN 20 mg, 1 tablet per day, quantity 79, was started on 07/7/2024, has six (6) tablets left in the bottle. However there is no record of refusal which indicated there are four (4) extra pills.

LPAs conducted interviews during the visit. LPAs obtained the following documents - Census, Staff schedule, and updated Limited Liability insurance.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, appeal rights discussed, and a copy of the report provided.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/21/2024 05:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(4)

Incidental Medical and Dental Care Services

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on medication review and LPA observation, the licensee did not comply with the section cited above as medication for Resident #2 (R2) medication ROSUVASTATIN 20 mg, was counted and was observed to have 4 more pills than needed. However there is no record of refusal documented which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/04/2024
	Plan of Correction
1 2 3 4	Licensee will conduct staff training on medications and submit proof to CCL no later than POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/21/2024 05:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(c)(3)

Incidental Medical and Dental Care Services

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on medication review and LPA observation, the licensee did not comply with the section cited above as three (3) out of four (4) PRN medication for R1 are being administered but is not being documented which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/04/2024
	Plan of Correction
1 2 3 4	Licensee will submit a plan describing how you will ensure residents medications will be properly administered and documented. Submit proof to CCL no later than POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/21/2024 05:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87633(a)(2)

Hospice Care for Terminally Ill Residents

(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (2) The licensee remains in substantial compliance with the requirements of this section, with the provisions of the Residential Care Facilities for the Elderly Act (Health and Safety Code Section 1569 et seq.), all other requirements of Chapter 8 of Title 22 of the California Code of Regulations governing Residential Care Facilities for the Elderly, and with all terms and conditions of the waiver. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and LPA observation, the licensee did not comply with the section cited above as facility has an approved hospice waiver for four (4) residents but facility has five (5) residents on hospice which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/04/2024
	Plan of Correction
1 2 3 4	Licensee has agreed to submit a hospice waiver increase to CCL no later than POC due date.

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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2024

LIC809 (FAS) - (06/04)

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