197602434-4-15-2021-29-AS-JAPL-C29RZZ-20210420132845

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197602434
Report Date: 04/15/2021
Date Signed: 04/15/2021 03:44:43 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/14/2021 and conducted by Evaluator Aja Richardson

COMPLAINT CONTROL NUMBER: 29-AS-20210414132129

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: 69	DATE:	04/15/2021
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Dion Gallarza, Administrator		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Staff not properly trained to administer medications.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) conducted an unannounced 10-day visit to investigate the above allegation. LPA met with the Administrator Dion Gallarza at 9:45 am and explained the reason for the visit.
During today's visit, LPA conducted interviews with the Administrator and Staff from 9:50 am to 11:32 am. At 10:30 am, LPA reviewed the facility files of staff who currently and previously assisted with medication administration. According to the record review 1 out of 4 staff who currently or previously in 2020 carried out Med Tech duties did not have current training in their files. Interviews with the Administrator and Staff revealed that they never received any medication certification or documentation that they had completed the required amount of medication training. Based on the lack of training documentation in staff files this allegation is Substantiated.
The following deficiencies were observed (See LIC 9099-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. The report was signed, however a copy of the signed report was emailed, along with the appeal rights.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja Richardson	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021

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-20210414132129

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 04/15/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/20/2021 Section Cited HSC 1569.69	1 2 3 4 5 6 7	Employees assisting residents with self-administration of medication; training requirements: Each residential care facility for the elderly licensed under this chapter shall ensure that each employee..assists residents with the self-administration of medications meets all of the following training requirements: This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The Administrator has agreed to do the following: 1. For the identified staff (med techs), submit the completed medications training hours for 2021. If identified staff did not receive the required training, communicate a plan as to when the staff will receive training. Submit plan to CCL by 4/20/2021.
	8 9 10 11 12 13 14	Based on interviews and record review 1 out of four facility staff failed meet the requirements of set by the health and safety code for medication training which poses a potential risk to residents in care.	8 9 10 11 12 13 14	2. Administrator agreed to complete training in 4 weeks.
	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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja Richardson	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021

LIC9099 (FAS) - (06/04)

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