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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609865
Report Date: 03/04/2022
Date Signed: 03/04/2022 02:40:04 PM

Document Has Been Signed on 03/04/2022 02:40 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,
, CA
FACILITY NAME:COTTAGES OF LAKE BALBOA 1, THEFACILITY NUMBER:
197609865
ADMINISTRATOR:LEVI, JUSTINFACILITY TYPE:
740
ADDRESS:6724 GAVIOTA AVETELEPHONE:
(747) 264-1004
CITY:LAKE BALBOASTATE: CAZIP CODE:
91406
CAPACITY: 6CENSUS: 6DATE:
03/04/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Justin LeviTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted a case management in conjunction with the complaint investigation to address issues related to the complaint (control #: 31-AS-20200109083157). During the investigation, conducted by the department’s Investigative Bureau (IB) and LPA it was reported through incident reports and facility documents, that R1 had two unwitnessed falls in which R1 sustained multiple bruises, a skin tear, and forehead contusion. From one of those falls, staff left R1 unattended on the floor for a period of time and did not seek medical attention nor notify R1’s responsible party in a timely manner. These are potential health and safety risks to residents in care.

Under Title 22, Division 6, Chapter 8, following deficiencies were cited and recorded on LIC 809 D.

Exit interview conducted. A copy of the report was issued. Appeal rights provided.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2022
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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Document Has Been Signed on 03/04/2022 02:40 PM - It Cannot Be Edited


Created By: Tuesday Cabiness On 03/04/2022 at 02:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
, CA

FACILITY NAME: COTTAGES OF LAKE BALBOA 1, THE
FACILITY NUMBER: 197609865

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
03/25/2022
Section Cited
CCR
87468.1

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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: (8)To have their representatives regularly informed by
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Administrator and LPA discussed the plan of correction, that the facility will ensure that any incidents related to residents, all family or representatives will be notified in a timely manner, and will continue to
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by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement was not met, evidenced by, based on information obtained R1 fell and staff did not notify R1's representative in timely a manner.
This is a potential health and safety risk to residents in care.
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submit SIRs to Licensing according to regulations. Training will be provided to all staff and documentation will be submitted to LPA by POC date.
Request Denied
Type B
03/25/2022
Section Cited
CCR87465(g)

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Incidental Medical and Dental
Care. (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but
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Administrator will discuss with staff, the proper protocols when a resident is injured and when to contact emergency personnell, as wwhen needed. Training will be provided and documentation will be
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not limited to, an apparent life-threatening medical crisis..This requirement was not met, evidenced by, based on R1 fell at the facility and staff did not provide medical attention to R1.
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submitted to LPA by POC date.
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:Cassandra Harris
LICENSING EVALUATOR NAME:Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022


LIC809 (FAS) - (06/04)
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