197602434-8-23-2021-29-AS-SWAR-C66QJ2-20210823121200

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197602434
Report Date: 08/23/2021
Date Signed: 08/23/2021 12:22:35 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
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: 72	DATE:	08/23/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:21 AM
MET WITH:	Dion Gallarza, Director		TIME COMPLETED:	12:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Salia Walker arrived at the facility unannounced to conduct a required Annual visit at 08:21 a.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Director Dion Gallarza at 08:34 a.m., and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside, with Director Dion Gallarza at 08:42 a.m., to ensure there are no health and safety hazards.

Kitchen: The kitchen area appeared clean and sanitary. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Food in the refrigerator/freezer were properly labeled. All knives and cleaning supplies were observed to be properly stored and locked at time of visit. At 09:02 a.m., hot water in kitchen measured 128.7 Fahrenheit. The LPA advised Director hot water temperature is to attain a temperature of not less than 105 degrees Fahrenheit (41 degree C) and not more than 120 degrees Fahrenheit (49 degree C). Director was advised this poses an immediate health and safety risk to residents in care.
Bedrooms: The LPA observed the resident bedrooms which were furnished with clean linens, appropriate furnishings, and sufficient lighting.
Bathrooms: Common and private bathrooms were clean, properly supplied and had functional fixtures. Between 09:09 a.m. and 09:15 a.m., hot water temperatures measured between 128.7 degrees Fahrenheit and 130 degrees Fahrenheit private bathroom(s) for room #111 and room #127 (located on the Assisted Living section of the facility). The LPA advised Director hot water temperature is to attain a temperature of not less than 105 degrees Fahrenheit (41 degree C) and not more than 120 degrees Fahrenheit (49 degree C). Director was advised this poses an immediate health and safety risk to residents in care.

Continue on LIC-809C..

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
	VISIT DATE: 08/23/2021

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Common Areas: Common areas include the dining room, activity rooms, and patios. In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. Fire extinguishers were observed throughout the facility, and were fully charged. At 08:45 a.m. the Laundry room, which contains detergent and other cleaning supplies, was observed not properly secured. This poses an immediate health and safety risk to residents in care.
Surrounding Grounds: Entry/exits were free of obstruction. Medication room: First aid kit, medications, and medication records are kept in the medication room.
BACKYARD: The backyards have covered outdoor areas equipped with furniture for resident use. There were no bodies of water noted. The facility is equipped with fire sprinklers.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Director regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time, and the LPA reviewed facility’s policies and procedures as it pertains to infection control.

The following deficiencies were observed (See LIC 809-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. A copy of the report and appeal rights were provided via email.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021

LIC809 (FAS) - (06/04)

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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
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: 08/23/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as the laundry room was observed not properly secured containing cleaning supplies and disinfectants accessible to residents, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 08/30/2021
	Plan of Correction
1 2 3 4	Director secured laundry room in memory care section during facility visit. The Director has agreed to do the following: 1. Provide documentation of scheduled staff training regarding regulation 87705(f)(2) to CCL by 8/30/21.

Type A

Section Cited

CCR

87303(e)(2)

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, the licensee failed to ensure hot water temperature measured within 105 to 120 degrees F in resident rooms which poses an immediate health, and safety risk to residents in care.
	POC Due Date: 08/30/2021
	Plan of Correction
1 2 3 4	The Director has agreed to do the following: 1. Submit proof by photos, and receipt of tempurature adjustment. 2. Submit a hot water temperature log for five (5) days to maintain water temperature between n 105 - 120 degrees F.

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: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021

LIC809 (FAS) - (06/04)

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