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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602434
Report Date: 08/28/2026
Date Signed: 08/28/2026 11:57:25 AM

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
11/06/2025 and conducted by Evaluator Christine Yee
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20251106161044
FACILITY NAME:GARDENS AT PARK BALBOA, THEFACILITY NUMBER:
197602434
ADMINISTRATOR:DION D GALLARZAFACILITY TYPE:
740
ADDRESS:7046 KESTER AVENUETELEPHONE:
(818) 787-0462
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY:120CENSUS: 101DATE:
08/28/2026
UNANNOUNCEDTIME BEGAN:
10:34 AM
MET WITH:Jonathan McFall, Marketing Director TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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1. Staff neglect led to resident developing pressure injuries while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Yee conducted a subsequent complaint visit to deliver findings for the above allegation. LPA Yee met with Jonathan McFall, Marketing Director since Dion Gallarza, Executive Director had scheduled training and was not on-site. The reason for today's visit was explained.

On 11/07/2025, from 12:00 pm to 3:15 pm, Licensing Program Analyst (LPA) Christine Yee conducted an unannounced initial complaint visit. LPA met with Executive Director Dion Gallarza and Wellness Director, Laura Diaz; toured the physical plant and obtained documentation on residents.

On the allegation: Staff neglect led to resident developing pressure injuries while in care. On 11/06/2025, the Department received a complaint, alleging that due to staff neglect, Resident #1 (R1) developed a stage 3 sacral pressure injury.

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 8
Control Number 29-AS-20251106161044
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: 08/28/2026
NARRATIVE
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Page 2.

The Department conducted the following interviews: on 11/19/2025 at approximately 11:30 am, interviewed the Executive Director; on 11/19/2025 at approximately 1:00 pm interviewed R1; on 12/4/2025 at approximately 12:00 pm interviewed staff; on 12/4/2025 at approximately 1:00 pm to 1:20 pm interviewed residents; on 12/9/2025 at approximately 2:30 pm, interviewed Family #1 (F1); on 12/29/2025 from approximately 2:00 pm to 2:30pm interviewed staff. The Department reviewed medical records for R1 from North Hills Rehab Center and from Kaiser Permanente. Records indicate that R1 had a left sacrum-pressure injury stage 3 on admission to the hospital dated 10/31/2025. Records state the pressure injury appears “over bony prominence, full thickness tissue loss, subcutaneous fat visible.” Record states R1 is diabetic and incontinent.

R1 was admitted to the facility on 10/10/2025. R1’s Preplacement Appraisal Form (LIC 603) dated 10/2/2025 and Service Care Plan dated 10/4/2025 state resident needs assistance with showers/bathing, and does not claim that R1 is incontinent at time of admission. On the following dates R1 had falls: 10/14/2025, 10/20/2025, 10/21/2025, 10/22/2025, and 10/31/2025, all of which were reported via an Unusual Incident report to CCL. R1 refused transport for all falls, except the final one on 10/31/2025.

Executive Director and Staff interviewed stated they were not aware of any pressure injuries, stated R1 was fairly independent, but staff assisted R1 with bathing and medication management. Health Services Director stated they do not perform any skin checks prior to admission unless the resident has a history of skin breakdown. Health Services Director stated they were aware of the regulations on pressure injuries, but erroneously believed Stage 1 and 2 can be monitored within the facility, while Stage 3 is allowed with home health wound care only. Staff stated they often saw R1 sitting on either R1’s bed or couch, stated R1 was not very mobile and was very stubborn, refused medical evaluation following multiple falls, and wanted to refuse medical evaluation on 10/31/2025. Staff interviewed confirmed their duties include showering and changing residents, and noted R1 often refused showers. All staff interviewed stated they assisted R1 with diaper changes, and some stated they had only given R1 one shower, while others denied ever providing R1


Continued on LIC9099-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 29-AS-20251106161044
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: 08/28/2026
NARRATIVE
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Page 3
a shower. Staff denied seeing any wounds on R1’s buttocks and/or sacrum. Some staff denied a pressure injury was ever mentioned to them, but during interview Staff 1 admitted that F1 had “asked about a pressure injury” but does not remember what was said about it.

When R1 was interviewed, they had no complaints about the care or staff. R1 stated they were not aware of the pressure injuries, and did not have any pain. R1 stated they could dress and toilet themselves, and stated the only time staff would have seen their body is during shower assistance. R1 stated they got themselves in and out of bed on their own, they liked to be up and moving around, and did not stay in bed or a chair often.

Review of shower schedule shows that R1 was scheduled for PM showers for Tuesday and Saturday. The facility had no records to show if any showers were refused. Based on the timeline, there would have been 6 showers given from 10/10/2025 through 10/31/2025 if the schedule was adhered to.

F1 stated approximately one week prior to R1 being admitted to the hospital on 10/31/2025, F1 observed what F1 determined to be a stage 2 pressure injury on R1 buttocks area. F1 described it as being “smaller than a dime.” F1 did not advise any staff, as F1 was going to directly request wound care through Kaiser. Approximately two to three days after F1 discovered the pressure injury, a caregiver (name unknown) told F1 that R1 had “a little sore on [R1’s] butt,” and R1 was admitted to the hospital “two to three days” after that. F1 stated they had professional medical training as a Registered Nurse and Nurse Practitioner. When asked to elaborate on the interaction with the caregiver, F1 stated they would often find R1’s adult diaper soiled and F1 would change and clean R1, as well as assist with showering R1 sometimes. F1 notified a caregiver that R1 was “dirty” and needed a shower after F1 found R1 “dirty” with feces. As F1 and the caregiver were showering R1, the caregiver made the comment about the “sore on [R1’s] butt.” F1 took R1 to their primary care physician on 10/30/2025 and discussed needing wound care. F1 indicated R1 did not have any sores when they arrived at the facility.

Other residents interviewed, who had been at the facility for multiple years, stated they had no complaints or concerns with their care and living arrangements.

Continued on LIC9099-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 29-AS-20251106161044
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: 08/28/2026
NARRATIVE
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Page 4.

The investigation provided sufficient evidence to substantiate neglect/lack of care. Per R1’s family, they observed a pressure injury on R1’s sacrum about one week prior to R1’s hospitalization (on 10/31/2025), and F1 advised a caregiver had also observed the pressure injury and commented about it. One staff interviewed confirmed F1 asked them about a pressure injury, but all staff denied observing or having knowledge of one. Per Kaiser Permanente Hospital medical records, R1 was admitted to the hospital on 10/31/2025 with a stage 3 community acquired pressure injury (CAPI) on R1’s sacrum.

Based on interviews and record review, there is a preponderance of evidence to support that the above allegation occurred, therefore, the allegation is SUBSTANTIATED.

Deficiency cited under Health and Safety Code, Chapter 3.2 Residential Care for the Elderly, Article 3

Immediate civil penalties of $500 was assessed on today's visit. Jonathan McFall was also informed that additional civil penalties may also be assessed based on Health and Safety Code 1569.49(e) or (f).



Exit interview was conducted, APPEALS RIGHTS was discussed and a copy was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 29-AS-20251106161044
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: 08/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/31/2026
Section Cited
HSC
1569.312(a)
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§1569.312 Basic services requirements:
Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. This requirement was not met evidenced by: Based on interviews and record review, the
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Licensee will submit a written plan on how the facility will ensure appropriate care and supervision to meet the needs of residents. Submit a copy of the plan to CCL by 8/31/26
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licensee did not comply with the section cited above when due to a lack of care and supervision by facility staff, R1 developed a stage 3 pressure injury, which posed an immediate health and safety risk to residents in care. Immediate civil penalties of $500 was assessed.
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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
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2026
LIC9099 (FAS) - (06/04)
Page: 8 of 8
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
11/06/2025 and conducted by Evaluator Christine Yee
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20251106161044

FACILITY NAME:GARDENS AT PARK BALBOA, THEFACILITY NUMBER:
197602434
ADMINISTRATOR:DION D GALLARZAFACILITY TYPE:
740
ADDRESS:7046 KESTER AVENUETELEPHONE:
(818) 787-0462
CITY:VAN NUYSSTATE:CAZIP CODE:
91405
CAPACITY:120CENSUS: 101DATE:
08/28/2026
UNANNOUNCEDTIME BEGAN:
10:34 AM
MET WITH:Jonathan McFall, Marketing DirectorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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2. Staff neglect led to resident sustaining skin tears while in care.
3. Staff are not properly supervising resident who is a fall risk
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Yee conducted a subsequent complaint visit to deliver findings for the above allegations. LPA Yee met with Jonathan McFall, Marketing Director since Dion Gallarza, Executive Director had scheduled training and was not on-site. The reason for today's visit was explained.

On 11/07/2025, from 12:00 pm to 3:15 pm, Licensing Program Analyst (LPA) Christine Yee conducted an unannounced initial complaint visit. LPA met with Executive Director Dion Gallarza and Wellness Director, Laura Diaz; toured the physical plant and obtained documentation on residents.

On the allegations: Staff neglect led to resident sustaining skin tears while in care and Staff are not properly supervising resident who is a fall risk.

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 29-AS-20251106161044
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: 08/28/2026
NARRATIVE
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The Department conducted the following interviews: on 11/19/2025 at approximately 11:30 am, interviewed the Executive Director; on 11/19/2025 at approximately 1:00 pm interviewed R1; on 12/4/2025 at approximately 12:00 pm interviewed staff; on 12/4/2025 at approximately 1:00 pm to 1:20 pm interviewed residents; on 12/9/2025 at approximately 2:30 pm, interviewed Family #1 (F1); on 12/29/2025 from approximately 2:00 pm to 2:30pm interviewed staff. The Department reviewed medical records for R1 from North Hills Rehab Center and from Kaiser Permanente.

R1 stated they had no issues with the care at the facility and were treated well. R1 stated they transfer in and out of bed independently and walk on their own, usually with a walker. R1 stated they fell from bed and staff was there to assist them “right away.” On the following dates R1 had falls: 10/14/2025, 10/20/2025, 10/21/2025, 10/22/2025, and 10/31/2025, all of which were reported via an Unusual Incident report to CCL. 9-1-1 was called for each fall, but R1 refused transport for all falls, except the final one on 10/31/2025. R1’s medical records from 10/31/2025 show R1 was diagnosed with a closed head injury, accidental fall, left elbow laceration, right elbow laceration, and left lower leg laceration. The medical records state R1 fell from bed with a head injury and has had recurrent falls over the past three to four weeks associated with progressive weakness, functional decline, and worsening cognition including memory loss and urinary incontinence. An MRI showed R1 had an acute lacunar infarct (ischemic stroke). Medical records state the first responders reported R1’s “bed was pretty high,” and one staff interviewed confirmed R1’s bed was high. Interviews from Health Service Director and staff confirm R1 had several falls within their approximate three-week stay in the facility. Health Service Director stated R1 was active and independent with transfers and walking, with the assistance of a walker, and wore a fall pendant. Health Service Director stated they had been working with F1 regarding the falls, and R1 had a doctor’s appointment just prior to the 10/31/2025 hospitalization. F1 was trying to determine why R1 was falling so much and wanted to discuss R1’s medications with the doctor. F1 also removed R1’s dog from the facility in case R1 was tripping over the dog. Staff interviewed also believed the dog could have been a factor in the falls. Staff interviewed stated they mentioned to F1 that a hospital bed would be beneficial, but one was not yet obtained. F1 stated they were aware R1 was deteriorating quickly and it was a “battle “ to keep R1 from falling. F1 confirmed they spoke


Continued on LIC9099-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 29-AS-20251106161044
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: 08/28/2026
NARRATIVE
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with the Health Services Director regarding the falls about two to three days before the 10/31/2025 hospitalization. F1 stated they discussed about R1 potentially needing a higher level of care, but nothing was decided upon. F1 confirmed R1 had a history of falls six to eight months prior to moving in. On 10/30/2025, F1 took R1 to their primary care physician to discuss medication management, physical therapy, and wound care, but those were not yet put into place by 10/31/2025. F1 also stated R1 tried to be independent but was also sure they could do things they could not handle, and was a “good liar” so as not to be a “burden.” F1 stated R1 initially refused to use their walker but began to use it more, although they also started refusing to go down for meals, which could be due to getting weaker.

Overall, although R1 had experienced multiple falls during a three-week period residing at the facility, measures had been taken to try to address the reasons for R1’s falls, R1 was reassessed by their doctor, and discussions had begun about a potential higher level of care. Based on all interviews conducted and documents obtained, at this time the above allegations were found to be unsubstantiated, meaning that the allegations may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview was conducted, copy of report and appeal rights were provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 8