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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602434
Report Date: 10/02/2025
Date Signed: 10/02/2025 12:30:03 PM

Document Has Been Signed on 10/02/2025 12:30 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/
DIRECTOR:		DION D GALLARZAFACILITY TYPE:
740
ADDRESS:7046 KESTER AVENUETELEPHONE:
(818) 787-0462
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY: 120CENSUS: 103DATE:
10/02/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:28 AM
MET WITH:Dion Gallarza - Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Quoc Huynh arrived unannounced at 9:28AM to conduct an Annual Continuation visit. The LPA met with the Executive Director (ED) Dion Gallarza and explained the reason for the visit. Entrance interview conducted.

At 9:31AM, the LPA and ED conducted a brief health and safety tour of the physical plants areas, and no immediate concerns were observed.

RECORDS: Resident records were reviewed at 9:57AM. LPA Huynh reviewed ten (10) files for, but not limited to: admissions agreements, medical assessment, appraisals, and consent forms. Resident records reviewed were in order at this time. The LPA reviewed eleven (11) personnel records for, but not limited to: job application, health assessments, TB results, criminal record statements and clearances, first aid/CPR certification, and appropriate trainings. Staff files reviewed were in compliance with regulation at this time. Three (3) staff did not have a certified first aid/CPR training on file, however, received Relias online module trainings and certified staff are on the premises at all times. The LPA advised the ED to ensure direct care staff receive first aid/CPR certification.

Report Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 10/02/2025
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INFECTION CONTROL/EMERGENCY DISASTER: The LPA reviewed the facility's Infection Control Plan and Emergency Disaster Plan. LPA noted that the facility is in compliance with regulation with both plans reviewed annually. The facility conducts emergency disaster drills monthly, with the last drill documented on 09/16/2025. Fire alarm system is tested annually with the last inspection on 05/01/2025. Additionally, the commercial kitchen was inspected on 08/30/2025 and fire doors were tested on 09/23/2025 by GFP Guard Fire Protection Services Inc.

MEDICATION: Medication review began at 11:30AM. The LPA reviewed medications for five (5) residents. Medications were maintained locked inaccessible to residents in the Medication Room located on the first floor in the Memory Care Unit. Resident medications reviewed were documented and stored in compliance with regulation at this time.

No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025
LIC809 (FAS) - (06/04)
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