197609868-9-13-2024-29-AS-SURA-D93R4T-20240913124205

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609868
Report Date: 09/13/2024
Date Signed: 09/13/2024 12:42:41 PM

Document Has Been Signed on 09/13/2024 12:42 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	COTTAGES OF LAKE BALBOA 2, THE		FACILITY NUMBER:	197609868
ADMINISTRATOR:	JUSTIN LEVI		FACILITY TYPE:	740
ADDRESS:	6728 GAVIOTA AVE		TELEPHONE:	(818) 616-9360
CITY:	LAKE BALBOA	STATE: CA	ZIP CODE:	91406
CAPACITY:	6	CENSUS: 0	DATE:	09/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:29 AM
MET WITH:	Justin Levi		TIME COMPLETED:	12:38 PM

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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual visit. The LPA met with Administrator Justin Levi and explained the reason for the visit.

The facility is currently vacant as they are awaiting to become vendored with Los Angeles Regional Center. LPA did not observe any residents at the time of the visit. No staff was present at the time of the visit.

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

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. One fire extinguisher was fully charged. The LPA observed required postings throughout the common space.

KITCHEN: Knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

BEDROOMS: The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident.

BATHROOMS: Bathrooms were sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

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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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 2, THE	FACILITY NUMBER: 197609868
	VISIT DATE: 09/13/2024

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OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. No bodies of water noted. The laundry area and staff room were located to the right of the entry way door. LPA observed room to be inaccessible to residents in care. The washer and dryer are located in a room adjacent to the staff room. Cleaning supplies and disinfectants are kept in locked in the laundry area.

RECORDS: No residents’ or staff records were reviewed at this time. The Administrator will inform the LPA when new residents are admitted, and staff start working. Once the LPA is informed, the LPA will return to review records.

MEDICATIONS: No medications were review at this time.

INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

LIC809 (FAS) - (06/04)

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