197602434-10-30-2024-29-AS-KHEN-DAL7U9-20241031215759

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197602434
Report Date: 10/30/2024
Date Signed: 10/30/2024 07:59:26 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
02/28/2023 and conducted by Evaluator Christine Yee

COMPLAINT CONTROL NUMBER: 29-AS-20230228172613

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: 104	DATE:	10/30/2024
		UNANNOUNCED	TIME BEGAN:	03:51 PM
MET WITH:	Dion Galarza, Executive Director		TIME COMPLETED:	08:15 PM

ALLEGATION(S):

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1. Staff assaulted a resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst(LPA) Christine Yee conducted an unannounced subsequent complaint visit to conduct further investigateion and to deliver the findings of the above allegations and met with Dion Galarza, Administrator. The reason for today's visit was explained.

During the initial visit conducted on 3/3/23, LPA Yee reviewed and obtained copies of facility records related to the complaint throughout the visit, interviewed the Administrator from 10:00am-10:33am, staff #4 at 10:39am-10:48am. Staff #1 is no longer employed by the facility, Staff #2 and Staff #3 were unable to be interviewed since it was their day off. Per review of the facility records and interviews conducted, further investigation is needed to make a finding for the above allegations.
Exit interview was conducted and a copy of the report was provided.

On today's visit, LPA Yee collected additional facility documents and attempted to interview Staff #2 but

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: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

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-20230228172613

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: 10/30/2024

NARRATIVE

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was advised that the Staff #2 was on vacation and was unavailable to be interviewed again.

Per interview conducted with the Executive Director, regarding allegation #1 - staff assaulted a resident in care, on the night of 5/27/22 he received a call from Staff #2 advising him that they observed Staff #1 grab Resident #1 by the right arm and shoved them to the ground. Resident #1 hit their head and sustain a cut above the left eye. The Executive Director came to the facility. Emergency services were contacted and they came out to assess Resident #1 and rendered first aid. The paramedics determined that Resident #1 did not need to be taken to the hospital. Per information provided, Resident #1's physician was notified of the incident and attempts were made to notify the resident's responsible party. A message to call the Administrator was left on the responsible party's voice mail but no return call was received. Per the Administrator, he did not leave a detailed message of the incident for the responsible party since it was bad news. The police was also contacted and they came out to investigate and left a ticket for the incident. The Executive Director spoke with Staff #1. Per information provided, Resident #1 was in their room and wanted to go out. Staff #1 was trying to re-direct the resident who was arguing with them and next thing Staff #1 remembers is that the resident was on the floor. Staff #1 does not know what happened. Per Staff #1, they were turning the resident around and they fell. Staff #1 was suspended and escorted out of the facility. On 6/2/22, Staff #1 was terminated in person. Staff #1 was determined not to be safe around residents. Management took the appropriate steps to mitigate any further abuse of Resident #1 or any other resident, intentionally or unintentionally by Staff #1, Based on the information received there is sufficient evidence to support the allegation that staff assaulted a resident in care, therefore the allegation is substantiated at this time.

Deficiencies were cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Immediate civil penalties of $500 was assessed.

Exit interview was conducted, Appeals Rights discussed and a copy was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230228172613

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: 10/30/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/31/2024 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities: Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding	1 2 3 4 5 6 7	Licensee will provide an action plan to ensure that staff will not abuse or get physical with the residents when they have a behavior or are difficult by10/31/24. Licensee will also ensure that staff are provided with regular personal rights training by November 6, 2024
	8 9 10 11 12 13 14	residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidenced by- Resident #1 was shoved by their caregiver which caused the resident to sustain a cut over the left eye. Immediate civil penalties were assessed	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
02/28/2023 and conducted by Evaluator Christine Yee

COMPLAINT CONTROL NUMBER: 29-AS-20230228172613

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: 104	DATE:	10/30/2024
		UNANNOUNCED	TIME BEGAN:	03:51 PM
MET WITH:	Dion Galarza, Executive Director		TIME COMPLETED:	08:15 PM

ALLEGATION(S):

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2. Resident's responsible party was not notified of an incident.

INVESTIGATION FINDINGS:

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Unsubstantiated

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: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 29-AS-20230228172613

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: 10/30/2024

NARRATIVE

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was advised that the Staff #2 was on vacation and was unavailable to be interviewed again.

Per information received regarding Allegation #2 - Resident's responsible party was not notified of an incident, the Executive Director and facility staff stated that they made attempts to reach Resident #1's responsible party and left a generic voice mail message to call the facility regarding this incident and their calls were not returned by the responsible party. Per the Executive Director, he does not like to leave bad news on a voice mail and prefers to notify family personally. According to information received, the responsible party does a lot of traveling and is not always available or is out of town for business and is very difficult to get a hold of. However, the responsible party denies receiving any calls regarding this incident.
Based on the information received, there is insufficient evidence to support the allegation that the resident's responsible party was not notified of an incident, therefore the allegation is unsubstantiated.

Exit interview was conducted and copy of this report was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC9099 (FAS) - (06/04)

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