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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602434
Report Date: 03/22/2022
Date Signed: 03/22/2022 03:28:38 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
03/11/2020 and conducted by Evaluator Salia Walker
COMPLAINT CONTROL NUMBER: 31-AS-20200311163113
FACILITY NAME:GARDENS AT PARK BALBOA, THEFACILITY NUMBER:
197602434
ADMINISTRATOR:JOHN PURDUEFACILITY TYPE:
740
ADDRESS:7046 KESTER AVENUETELEPHONE:
(818) 787-0462
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY:120CENSUS: 74DATE:
03/22/2022
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Dion Gallarza, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility overcharged resident in care

Facility did not provide an itemized statement for resident's care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Salia Walker arrived unannounced for a subsequent complaint visit. The purpose of the visit is to deliver the findings for an investigation initiated by LPA Aja Richardson on 03/24/2020. The LPA met with Administrator Dion Gallarza at 12:40 p.m., and explained the reason for the visit.

On 03/24/2020, LPA Aja Richardson initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted telephonically. At 11:30 a.m., LPA Richardson conducted a telephonic interview with the administrator, John Perdue. The LPA determined, at that time, that further investigation was required.

Continue on LIC9099C..
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
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 4
Control Number 31-AS-20200311163113
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
VISIT DATE: 03/22/2022
NARRATIVE
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On 08/23/2021, LPA Salia Walker conducted an unannounced subsequent visit for the above allegations. Between 12:00 p.m. and 12:41 p.m., the LPA conducted a record review, and obtained copies of records pertinent to the investigation. The LPA determined, at that time, that further investigation was required.

On 12/21/2021, LPA Walker conducted an unannounced subsequent visit. From 12:16 p.m. until 12:43 p.m.; and between 3:08 p.m. until 4:12 p.m., the LPA conducted interviews with three (3) staff. From 12:54 p.m. until 1:40 p.m., the LPA conducted an interview with the administrator. Additional copies of documents pertinent to the investigation were reviewed, and obtained The LPA determined, at that time, that further investigation was required.

During today’s visit, the LPA conducted a physical plant tour with the Administrator at 1:00 p.m., to ensure there are no health and safety hazards.

Regarding the allegation, ‘Facility overcharged resident in care,’ the complainant’s concern is that Resident #1 (R1) was overcharged for the months leading up to 03/2020. The complainant stated R1 received back-payment statements on 02/2020 and 03/2020, for additional services R1 allegedly did not require.

To conduct the investigation, LPA Walker conducted a record review and an interview with the Administrator. The record review revealed that R1’s monthly rate was $2700 per month. A $500 deposit was applied to the first month’s rent. R1 had a remaining balance due of $643.80 thereafter. R1 was billed in April 2019, and the facility received payment of $3,232.50; which left a remaining balance of $111.30 due. In May 2019, the facility charged an additional $25 for laundry. That left the balance to be $2,836.30. R1 paid the $2700, however, with the $111.30 remaining due plus the $25, R1’s balances owed was $136.30. In June 2019, R1 was charged $2700. However, May 2019’s check for $2700 was returned, which left an outstanding balance of $5536.30. On June 24, 2019, the facility received payment for $2700. R1 still owed $2700 for the returned check in May, plus the $136.30 left over. It was in the month of June when it was determined that R1 required ‘Assisted Living Services.’

Continue on LIC9099C..
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20200311163113
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
VISIT DATE: 03/22/2022
NARRATIVE
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The LPA spoke with the administrator to discuss whether or not R1 had a re-appraisal to where it was determined that R1 required additional services which cost $272.17; and, if the responsible party was notified for the month of June. The administrator acknowledged that there were charge(s) the facility made to R1 for the month of June 2019. There was no record of a re-appraisal, specified charge(s), and that the responsible party was notified. In July 2019, R1 was charged $2700 plus $487.00 for Assisted Living Service, which consisted of incontinent care. The LPA again followed-up to determine if a reappraisal had been conducted and if the responsible party was notified. The facility did not receive any payment in July 2019, which added to the existing balance. On August 1, 2019, R1 was charged the monthly rate of $2700, plus the $487.00 Assisted Living Service, and a charge of $250 late payment fee. On August 12, 2019, the facility received a payment of $2700. On August 23, 2019, the facility issued another late payment fee of $250. From August 2019 through January 2020, the facility received monthly payments of $2700. However, the facility was still charging late payment fees that continued to accrue with an additional laundry charge of $30. Record review revealed that R1’s condition began declining, and the facility provided a pendant on January 2020 for an additional $200 per month. On January 10, 2020, R1’s Assisted Living Services increased to $760.10 due to a ‘Change in condition.’ The LPA followed-up to determine if another reappraisal had been conducted. Although R1’s payments accumulated in $1000 late charges, the facility stopped charging the $250 late fees in November 2019. As noted above, the interview with the Administrator revealed that if staff notice that a resident’s ‘needs and services’ have changed, a re-assessment evaluation is done by the nurse on duty. Interviews also revealed that the facility cannot stop Assisted Living Services to residents if changes in condition require the care.

Based on record review, and interviews with the administrator, the facility determined that R1’s health condition was declining, and re-assessments were conducted to account for service charges that were made. The facility had evidence that they notified the responsible party of the reappraisals, and the required Assisted Living Service fee as required. Although in June 2019, there were no records of a re-appraisal, specified charge(s), and that the responsible party was notified in June 2019. The facility 'converted' all outstanding fees owed by R1. Therefore, there is insufficient evidence to support the allegation ‘Facility overcharged resident in care.’ Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time.
Continue on LIC9099C..
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20200311163113
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
VISIT DATE: 03/22/2022
NARRATIVE
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Regarding the allegation, ‘Facility did not provide an itemized statement for resident's care,’ the complainant’s concern is that R1 did not receive any notices of payment in the previous months.

During the investigation, LPA Walker conducted a record review. Record review revealed, that the facility provided invoices, and rent increase notifications to R1 who was responsible for themselves. Record review also revealed, the facility communicated with R1’s family via email regarding assessment and service plan explaining level of care requiring need for additional services.

Based on record review, the facility did provide itemized statements for resident #1’s (R1’s) care, and was in communication with R1’s family. Therefore, there is insufficient evidence to support the allegation ‘Facility did not provide an itemized statement for resident's care.’ Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time.

Exit interview conducted. A copy of the report was provided.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4