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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602434
Report Date: 06/01/2022
Date Signed: 06/01/2022 04:25:15 PM


Document Has Been Signed on 06/01/2022 04:25 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: 80DATE:
06/01/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Dion Gallarza, AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Salia Walker initiated a Case Management-Incident visit to the facility above. The purpose of this visit is to follow up on a self-reported suspected dependent adult/elder abuse (SOC341), and Unusual Incident Report submitted to the department on 05/28/2022. Upon entry, the LPA met with Administrator Dion Gallarza and explained the reason for the visit.

On 5/28/2022, the facility submitted a suspected dependent adult/elder abuse (SOC341), and Unusual Incident Report, alleging that on 5/27/2022, Staff #1 (S1) reported that they witnessed Staff #2 (S2) physically abuse Resident #1 (R1). It was alleged that R1 became aggressive towards S2, to which S2 allegedly reacted and grabbed R1 by the right arm and then pushed R1 to the ground causing bleeding to the left side of R1’s face. S1 alleged that this incident took place in the facility’s “safe Haven” area during a shift switch. S1 notified management of this incident on 5/27/2022. In response, the facility notified the Local Ombudsman, Community Care Licensing, the Los Angeles Police Department, and attempted to contact responsible party for R1 to reported the incident.

During today’s visit, the LPA conducted a physical plant tour; interviewed the Administrator at 2:38 p.m.; conducted an interview with staff at 3:30 p.m.; and obtained copies of documents pertinent to the investigation. The LPA observed R1, whom appeared in good health and with no immediate concerns. No immediate health and safety concerns were observed during today’s visit.

Further investigation is required prior to issuing findings. 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: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2022
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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