197602434-9-27-2023-29-AS-CYEE-CW4373-20230927175916

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197602434
Report Date: 09/27/2023
Date Signed: 09/27/2023 05:59:23 PM

Document Has Been Signed on 09/27/2023 05:59 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: 98	DATE:	09/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Dion D. Gallarza, Administrator		TIME COMPLETED:	06:10 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 Analyst(LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool. The visit was conducted with Dion Gallarza, Administrator and the reason for today's visit was explained. The facility is a large 2 storey commercial building that consists of 101 resident bedrooms, 59 rooms are located downstairs and 42 rooms are upstairs. Bedrooms all have full private bathrooms. The first floor houses the main offices, dining room, kitchen and the lounge in addition to the resident bedrooms and the second floor has 2 offices, activity room for arts and crafts and the remaining resident rooms. The facility is licensed for 120 residents and 40 may be Non-ambulatory. The following domains were reviewed on today's visit: Infection Control, Operational Requirements and Staffing. Due to time constraints, the remaining domains will be reviewed on a return visit. During today's visit, LPA Yee reviewed the Infection Control Plan and portions of the Plan of Operations relevant to the 3 domains reviewed. 10 staff files were also reviewed. Citations were issued based on the deficiencies observed during the review of the 3 domains. Any deficiencies not cited on today's visit will be cited on a return visit. Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Exit interview was conducted, Appeals Rights were 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: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

Document Has Been Signed on 09/27/2023 05:59 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: 09/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(f)(1)

Incidental Medical and Dental Care Services

(f) Emergency care requirements shall include the following: (1) The name, address, and telephone number of each resident's physician and dentist shall be readily available to that resident, the licensee, and facility staff. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and observation, the licensee did not comply with the section cited above per request to verify the the names of the residents and the names of their physicians and dentist, address and contact information and the facility was not able to easily provvide the requested information which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/04/2023
	Plan of Correction
1 2 3 4	Licensee will ensure that the facility maintains the name, address and telephone number of each resident's physician and dentist and make it easily available to the resident, Licensee and facility staff by 10/04/23.

Type B

Section Cited

CCR

87411(c)(1)

87411 Personnel Requirements General:(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above per review of 10 staff files, there was no evidence of current first aid training maintained in staff files except for Grace Bulaclac. LPA was not able to establish if staff have taken current first aid training, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/11/2023
	Plan of Correction
1 2 3 4	Licensee will review all staff files to ensure that all staff have received first aid training and maintain evidence in the staff's files. If staff have not received first aid training, Licensee will provide a plan of aciton as to how the facility will ensure that there is a staff with first aid training, always present at the facility until all staff have received first aid and CPR training by 9/28/23.

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: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2