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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602434
Report Date: 05/16/2022
Date Signed: 05/16/2022 12:00:29 PM

Substantiated


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
01/25/2021 and conducted by Evaluator Salia Walker
COMPLAINT CONTROL NUMBER: 29-AS-20210125142107
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
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Dion Gallarza, AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff did not respond to residents call button
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Salia Walker arrived unannounced for a subsequent complaint inspection to deliver the findings for the above allegations. The LPA met with Administrator Dion Gallarza at 9:35 a.m., and explained the reason for the visit.

On 02/03/2021, 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 virtually with Administrator Dion Gallarza. At 12:00 p.m., LPA Richardson conducted an interview with the Administrator as well as requested facility resident records. The LPA determined further investigation was required at that time.

Continue on LIC9099C..
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 29-AS-20210125142107
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: 05/16/2022
NARRATIVE
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On 04/20/2022, LPA Walker conducted a subsequent complaint inspection for the above allegations. During the visit, the LPA conducted a physical plant tour with Business Office Manager, Katia Arriaga, at 9:31 a.m. From 9:55 a.m. until 10:45 a.m., the LPA reviewed and obtained copies of documents pertinent to the investigation. From 11:10 a.m. until 12:30 p.m.; and, between 3:10 p.m. until 3:45 p.m., the LPA conducted interviews with facility staff. From 1:52 p.m. until 3:10 p.m., the LPA conducted interviews with facility residents. The LPA determined further investigation was required at that time.

Regarding the allegation, ‘Staff did not respond to residents call button,’ the complainant’s concern is that Resident #1 (R1) had a device that is supposed to alert staff when R1 falls; however, the complainant alleged that they were informed that staff never came after the falls. The complainant is also concerned that when staff did not respond to the call button, R1 then had to yell for staff to assist R1.

LPA Walker attempted to contact the complainant and R1’s family member, as R1 passed away, but did not receive a response.

LPA Walker also conducted interviews with the administrator and facility staff; as well as a record review. The administrator revealed that R1 had a pendant provided by the facility that detects falls; so, it would have detected if R1 fell. The administrator also revealed that R1 would not wear the pendant. The administrator recalled an incident where R1 was found by the facility Medication Technician (Med Tech) on the floor; however, R1 was not wearing their pendant. According to the Administrator, staff response time to pendant calls is between 1 to 5 minutes; and, the highest wait time would be around 11 minutes.

Interviews with staff revealed that facility staff are provided a “pager” that notifies all staff when residents press on their call button or a fall is detected. Staff also confirmed that R1 would take off the pendant and the Med Tech would ask R1 why they kept taking it off. R1 would state that they forgot. There were also times that R1 would take off their pendant and staff had to look everywhere to try and locate it. Interviews with staff also revealed that due to R1’s decline in health condition, the facility had to conduct more routine checks to monitor R1.

Continue on LIC 9099C..

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
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 29-AS-20210125142107
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: 05/16/2022
NARRATIVE
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Record review revealed that R1 pressed on their pendant on different occasions, and there were times that facility staff responded well above 5 minutes of wait time.

In the month of January 2021, there were thirteen (13) different dates R1 pressed on their pendant multiple times, and staff’s response time ranged from 5 minutes up to 26 minutes. Two (2) out of thirteen (13) of these dates’ a response was required, but R1 was never responded to.

On 1/19/2021 at 10:11:22 a.m., R1 pressed their pendant “Announced” 9 times. A response was required, but not received; This alert was never responded to.

On 1/13/2021 at 5:57:59 a.m., R1 pressed their pendant “Announced” 9 times. A response was required, but not received; this alert was never responded to.

Based on interviews which were conducted and record review, facility staff often did not respond in a timely manner when R1 called or pressed their pendant during fall(s), which will be addressed in a case management visit; and, there were at least two occasions in the month of January 2021 that facility staff never responded at all. Therefore, there is sufficient evidence to support the allegation ‘Staff did not respond to residents call button’; as a result, the above allegation is found to be Substantiated.



The following deficiency was 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, and appeal rights discussed. A copy of the report, and appeal rights were issued.
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
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 29-AS-20210125142107
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: 05/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/23/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidenced by:
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The Licensee has agreed to do the following:
1. Provide training on Personal Rights and Process and Procedure on the call monitoring system for time efficiency to staff.
2. Submit proof of training to CCLD.
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Based on record review, and interviews conducted, the licensee did not comply with the section cited above as the facility did not respond to two (2) of R1’s calls for assistance, which poses an immediate health, safety, personal rights risk to persons in care.
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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: 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
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
01/25/2021 and conducted by Evaluator Salia Walker
COMPLAINT CONTROL NUMBER: 29-AS-20210125142107

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
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Dion Gallarza, AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility staff did not seek medical attention for resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Salia Walker arrived unannounced for a subsequent complaint inspection to deliver the findings for the above allegations. The LPA met with Administrator Dion Gallarza at 9:35 a.m., and explained the reason for the visit.

On 02/03/2021, 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 virtually with Administrator Dion Gallarza. At 12:00 pm, LPA Richardson conducted an interview with the Administrator as well as requested facility resident records. The LPA determined further investigation was required at that time.

Continue on LIC 9099C..
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 29-AS-20210125142107
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: 05/16/2022
NARRATIVE
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On 04/20/2022, LPA Walker conducted a subsequent complaint inspection for the above allegations. During the visit, the LPA conducted a physical plant tour with Business Office Manager, Katia Arriaga, at 9:31 a.m. From 9:55 a.m. until 10:45 a.m., the LPA reviewed and obtained copies of documents pertinent to the investigation. From 11:10 a.m. until 12:30 p.m.; and, between 3:10 p.m. until 3:45 p.m., the LPA conducted interviews with facility staff. From 1:52 p.m. until 3:10 p.m., the LPA conducted interviews with facility residents. The LPA determined further investigation was required at that time.

Regarding the allegation, ‘Facility staff did not seek medical attention for resident,’ the complainant’s concern is that on 01/14/21 resident #1 (R1) made staff aware they were having chest pains and asked the staff to take them to the hospital. The complainant is also concerned that the staff allegedly told R1 the facility had no staff to take R1 to the hospital. Therefore, R1 had to wheel themselves across the street in their wheelchair to the hospital.

During the investigation, LPA’s Richardson and Walker conducted interviews with the administrator. LPA Walker also conducted interviews with facility staff and residents. To conduct a thorough investigation, LPA Walker attempted to contact the complainant and R1’s family member; as R1 had passed away. The LPA was unsuccessful in reaching the complainant or R1’s family member.

Interviews with the administrator revealed that on 01/14/21, staff called 9-1-1 upon R1 informing them of R1 was not feeling well; however, R1 requested that the facility transport them to the hospital through the facility bus. The administrator revealed that staff advised R1 the facility could not transport R1 in emergency situations. The Administrator stated that the facility does not take residents to the hospital in emergency situations and that staff are to call 9-1-1/paramedics instead, for liability purposes. As a result, the Administrator revealed that R1 took off to the hospital in their motorized wheelchair/ scooter, because R1 did not want to pay for the ambulance. According to the administrator, R1 told staff that the facility could not tell R1 what to do, that R1 was independent, and can go where they wanted. The paramedics arrived at the facility shortly after R1 left.

Continue on LIC 9099C..
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
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20210125142107
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: 05/16/2022
NARRATIVE
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Interviews with staff revealed that R1 ‘would use their electric wheelchair to go the store,’ and that R1 ‘was more on the independent side.’ Interviews with staff also revealed that R1 used an electric wheelchair to take themselves to the hospital, because R1 ‘did not want to wait for the paramedics,’ and left the facility stating, “I’m independent; if I want to take myself to the hospital, I can!” Interviews with staff confirmed that ‘the facility is not allowed to transport residents to hospitals; and, that staff should ‘call 9-1-1 or call private ambulance.’

Interviews with residents revealed that the facility provides transportation to doctor appointments and that ‘staff calls 9-1-1 if it is an emergency.’

Based on interviews with the administrator, staff, and facility residents, the facility staff do seek medical attention for facility residents by calling 9-1-1 or a private ambulance when needed or requested. Therefore, there is insufficient evidence to support the allegation that ‘Facility staff did not seek medical attention for resident.’ As a result, the allegation is Unsubstantiated at this time.

No deficiencies cited. Exit interview conducted, and a copy of the report was emailed.
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
LIC9099 (FAS) - (06/04)
Page: 7 of 7