<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602434
Report Date: 05/16/2022
Date Signed: 05/16/2022 12:02:51 PM


Document Has Been Signed on 05/16/2022 12:02 PM - It Cannot Be Edited

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, THEFACILITY NUMBER:
197602434
ADMINISTRATOR:DION D GALLARZAFACILITY TYPE:
740
ADDRESS:7046 KESTER AVENUETELEPHONE:
(818) 787-0462
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY:120CENSUS: 78DATE:
05/16/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Dion Gallarza, AdministratorTIME COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Salia Walker conducted an unannounced Case Management- Deficiencies visit in conjunction with complaint control # 29-AS-20210125142107. At 9:35 a.m., the LPA met with Administrator Dion Gallarza, and explained the reason for the visit.

During the investigation of complaint control # 29-AS-20210125142107, LPA Walker spoke with the Administrator. The administrator informed the LPA that Resident #1 (R1) passed away. The LPA advised the administrator that CDSS does not have record of R1’s death report, and inquired as to whether the facility submitted the Death Report to Licensing or the previous assigned LPA. The administrator stated that R1 passed away in a Hospital, and not in the facility. The LPA advised the administrator that a written report shall be submitted to the licensing agency within seven days of any Death of any resident from any cause regardless of where the death occurred, including a hospital.

During the investigation, the LPA conducted a record review. Record review revealed, that the facility staff often did not respond in a timely manner when Resident #1 (R1) called or pressed their pendant during fall(s), and/or for different purposes requesting service. On 12/24/2020 at 10:51:33 a.m., R1 pressed their pendant “Announced” 8 times, staff responded at 11:30 a.m. 39 mins after. On 12/22/2020 at 10:43:59 a.m., R1 pressed their pendant “Announced” 5 times, staff responded at 11:05 a.m. 22 mins after. On 1/20/2021 at 10:56:48 a.m., R1 pressed their pendant “Announced” 6 times, staff responded at 11:22 a.m. 26 mins after. On 1/17/2021 at 9:30:29 a.m., R1 pressed their pendant “Announced” 5 times, staff responded at 9:50 a.m. 20 mins after. On 1/30/2021 at 7:38:17 a.m., R1 pressed their pendant “Announced” 5 times, staff responded at 7:59 a.m. 21 mins after. On 2/18/2021 at 4:42:03 p.m., R1 pressed their pendant “Announced” 4 times, staff responded at 4:59 p.m. 17 mins. On 2/16/2021 at 4:51:10 p.m., R1 pressed their pendant “Announced” 6 times, staff responded at 5:20 p.m. 29 mins after.
Continue on LIC 809C..
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-326-5838
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


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: 05/16/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 The LPA advised the Administrator that the facility is responsible for ensuring residents are provided care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. The LPA also advised the Administrator facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.

Pursuant to Title 22 of the California Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, today's reports and appeal rights were provided.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-326-5838
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/16/2022 12:02 PM - It Cannot Be Edited

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: 05/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/23/2022
Section Cited

1
2
3
4
5
6
7
87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing Agency.. the following: (1)A written report.. within seven days of the occurrence of..(A) Death of any resident.. regardless of where the death occurred..
This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on record review and interview with the administrator, the licensee failed to comply with the section cited above as the facility failed to submit R1's Death Report as required, which poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14

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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-326-5838
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 05/16/2022 12:02 PM - It Cannot Be Edited

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: 05/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/23/2022
Section Cited

1
2
3
4
5
6
7
87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities (a)In addition.. residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4)To care, supervision, and services..
This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on record review, and interviews conducted, the licensee did not comply with the section cited above as the facility did not respond to R1’s calls for assistance in a timely manner, which poses an immediate health, safety, personal rights risk to persons in care.
8
9
10
11
12
13
14
Type A
05/23/2022
Section Cited

1
2
3
4
5
6
7
87411(a)Personnel Requirements: Facility personnel shall at all times be sufficient in numbers..to provide the services necessary to meet resident needs..facilities licensed for sixteen or more, sufficient support staff.. to ensure..personal assistance and care..
This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on record review, and interviews conducted, the licensee did not comply with the section cited above as the facility did not respond to R1’s calls for assistance in a timely manner to meet R1’s needs, which poses an immediate health, safety, personal rights risk to persons in care.
8
9
10
11
12
13
14
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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-326-5838
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4