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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609865
Report Date: 09/01/2026
Date Signed: 09/02/2026 08:25:32 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/02/2026 08:25 AM - It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:COTTAGES OF LAKE BALBOA 1, THEFACILITY NUMBER:
197609865
ADMINISTRATOR/
DIRECTOR:		LEVI, JUSTINFACILITY TYPE:
740
ADDRESS:6724 GAVIOTA AVETELEPHONE:
(747) 264-1004
CITY:LAKE BALBOASTATE: CAZIP CODE:
91406
CAPACITY: 6CENSUS: 0DATE:
09/01/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:08 AM
MET WITH:Justin LeviTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct the required annual inspection. The LPA met with the Administrator Justin Levi and explained the reason for the visit. At the time of the visit, the facility had 0 residents. The facility has been vacant (no residents) for three consecutive years. During today’s visit the LPA was advised that the facility will have a Change of Ownership. The future licensee/administrator was at the facility during today’s visit and reported that they submitted an application to the Centralized Application Branch (CAB) approximately one month and a half ago and have gone through the fire inspection.

The LPA and the Administrator/and Applicant toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and that the facility is in compliance with Title 22 Regulations.

COMMON AREAS: At the time of the visit, the living room and dining room furniture was observed to be in good condition. Living room area needs to be cleared of storage items (frames, wall pictures, etc.)The facility maintained a comfortable temperature. The ceiling air exhaust in the living room area was observed to have dust and dirt. Smoke detectors and carbon monoxide detectors were recently tested by the fire inspector. One fire extinguisher was fully charged and was last serviced on 02/02/2026. The LPA observed the required licensing information (Emergency exiting floor plan, resident's personal rights, Ombudsman information, Theft and loss policy and Emergency telephone numbers) were posted on the facility's wall near the front entrance. There is a foyer area between bedrooms #1 and #2 and the first bathroom. This area needs to be cleared. During the visit the LPA observed chemicals, a chainsaw and other items that are accessible and pose an immediate danger to potential residents. The hallway areas are missing night lights for safe passage from bedrooms #1 and #2 to the bathroom, and hallway from bedrooms #3, #4, and #5. Four (4) nightlights need to be installed. Remove table and printer next to bathroom #1 door.

Kasandra Lopez
Sandra Urena
DATE: 09/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COTTAGES OF LAKE BALBOA 1, THE
FACILITY NUMBER: 197609865
VISIT DATE: 09/01/2026
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KITCHEN: Knives and cleaning supplies are to be stored inaccessible to residents in care. The knives and sharp objects drawer is missing the padlock. At the time of the visit, knives were not available at the facility. The Administrator stated that most of the utensils were relocated to the other facilities in the property, since this facility does not have residents. Kitchen appliances were in operable condition. Hot water temperature measured at 133.2 degrees. Due to the facility not having residents in the past three (3) years, the 7-day supply of non-perishable food and water is not available. Two 25-year buckets of non-perishable food were observed on a top shelf in the laundry room. However, the Administrator could not bring them down to be inspected by the LPA. A new supply will be purchased in the near future. Kitchen cupboards and cabinets were observed to in need of deep cleaning. Under sink cabinet was observed with chemicals and unlocked. BEDROOMS: The floor plan is approved for six residents’ rooms and one staff room. There was a linen closet in the hallway with extra towels and linens. The residents’ bedrooms are in the process of being remodeled and have some furniture, however the rooms need to be cleared of clutter. All rooms are single occupancy. Bedrooms #2, #4, and #6 have direct exit to the exterior perimeter of the facility. All bedrooms need to have fully made beds (sheets, blanket, comforter, pillows), trash cans with lids, a chair, closets cleared of all items, nightstand with lamp and flashlights. Bedroom #6 sliding screen door is in disrepair, needs to be fixed. Floor area next to the sliding door is broken and needs repair. BATHROOMS: There are two (2) bathrooms in the facility. Bathroom #1 was relatively clean and sanitary and in operating condition with grab bars non-skid surfaces, needs to have the sink water faucet secured as it was observed to be wobbly during the water temperature test. Both bathrooms were sufficiently stocked with soap and paper towels. Both bathrooms are missing a trashcan with tight fitting lid. Bathroom #2 needs a non-skid mat, needs to have the threshold floor repaired as it shows signs of wear and is broken. Hot water temperature measured at 131.5 degrees Fahrenheit in both bathrooms. OUTDOOR AREA: The backyard has outdoor area equipped with furniture for client use. Shade is missing. A patio umbrella will be added to provide shade. No bodies of water noted. The washer and dryer are in a room adjacent to the staff room. Cleaning supplies and disinfectants are kept locked in the laundry area. The LPA observed room unlocked. The Administrator was reminded that the room must be locked at all times. The passage way cleared and approved by the fire department must be free of clutter, during the visit the LPA observed several items blocking the passageway; furthermore a car is partially blocking the gate cleared by fire department as a fire exit. RECORDS: No residents’ or staff records were reviewed at this time. MEDICATION: No medication was audited at this time.

Technical Violations were issued as no residents are currently admitted at the facility. Exit interview conducted. A copy of the report was issued.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Sandra Urena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2026
LIC809 (FAS) - (06/04)
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