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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609868
Report Date: 09/24/2026
Date Signed: 09/24/2026 05:11:18 PM

Document Has Been Signed on 09/24/2026 05:11 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, THEFACILITY NUMBER:
197609868
ADMINISTRATOR/
DIRECTOR:		JUSTIN LEVIFACILITY TYPE:
740
ADDRESS:6728 GAVIOTA AVETELEPHONE:
(818) 616-9360
CITY:LAKE BALBOASTATE: CAZIP CODE:
91406
CAPACITY: 6CENSUS: 3DATE:
09/24/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Daniel LimTIME VISIT/
INSPECTION COMPLETED:
05:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sandra Urena arrived unannounced at the facility to conduct the required annual inspection. The LPA was greeted by staff and informed them of the reason for the visit. The staff informed the Administrator of the visit. The LPA explained the reason for the visit to the staff Daniel Lim. The LPA and the staff 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. The fire extinguisher was fully charged and was last purchased on 02/05/2026. The exhaust vent above the dining room table was observed to have dust accumulated on the vents and was observed to have some type of foreign object stuck on the vent. One smoke alarm device near one of the exit doors was missing, with wires exposed and a second smoke detector was not functioning . The Community Care Licensing Poster was not posted at the time of the inspection. The LPA observed most of the required postings throughout the common space. Motion sensor night lights were missing in the hallways leading to the bathrooms.

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. The hot water temperature measured 119.7 degrees Fahrenheit. The refrigerator and the freezer do not have a thermometer to ensure that the refrigerator and freezer are kept at the required temperatures (40 degree -0 degrees). Continues on LIC 809C..page 2

Kasandra Lopez
Sandra Urena
DATE: 09/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 14
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 2, THE
FACILITY NUMBER: 197609868
VISIT DATE: 09/24/2026
NARRATIVE
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The LPA observed at least three (3) Ziplock baggies of food with dates written on them; however, the baggies were not labeled with the content of the food inside the baggies. Furthermore, a ziplock baggie with a powder was observed in the pantry cabinet and did not have a label to identify the contents. Kitchen drawers, cupboards, and dishwasher were observed to be dirty and unsanitary.

BEDROOMS: There are six (6) residents’ private bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The LPA made the following observations. Bedrooms 4, 3, and 1 are currently vacant. The sliding closet door for Bedroom 3 needs to be fixed as it is currently coming off the rails when open. Bedroom 4 closet must be emptied as it currently has items that belonged to a previous resident. Closet in bedroom #1 was observed to have cobwebs and dusty.

BATHROOMS: The facility has three full bathrooms. Two bathrooms are considered common bathrooms for residents’ use, and one bathroom is a private bathroom #3 located inside bedroom 1. The common bathroom #1, has a broken toilet paper holder, and is missing a nonskid mat; and toilet grab bars. The common bathroom #2 has portable toilet grab bars that show signs of wear with some areas of the metal areas rusted, which pose a danger to residents in care and is missing a nonskid mat. Additionally, a trashcan without a lid was observed in bathroom #2 and the private bathroom #3.The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature measured 119.7degrees Fahrenheit.

OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. No bodies of water noted. Cleaning supplies and disinfectants are kept in locked cabinets.

RECORDS: Records review began at 12:54 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

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

DATE: 09/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026
LIC809 (FAS) - (06/04)
Page: 3 of 14
Document Has Been Signed on 09/24/2026 05:11 PM - It Cannot Be Edited


Created By: Sandra Urena On 09/24/2026 at 03:54 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COTTAGES OF LAKE BALBOA 2, THE
FACILITY NUMBER: 197609868

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on [(observation), the licensee did not comply with the section cited above as the facility failed to have a carbon monoxide detector in the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/25/2026
Plan of Correction
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Administrator will install a carbon monoxide detector by POC date and send pictures to the LPA via text.
Type A
Section Cited
CCR
87303(e)(4)
Maintenance and Operation
(4) Grab bars shall be maintained for each toilet, bathtub and shower used by residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) the licensee did not comply with the section cited above, as three out of three toilets didnot have a brab bars, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/25/2026
Plan of Correction
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Administrator will install the grab bars by POC date and will email pictures to LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Sandra Urena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2026


LIC809 (FAS) - (06/04)
Page: 4 of 14
Document Has Been Signed on 09/24/2026 05:11 PM - It Cannot Be Edited


Created By: Sandra Urena On 09/24/2026 at 03:54 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COTTAGES OF LAKE BALBOA 2, THE
FACILITY NUMBER: 197609868

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(5) Slip-resistant mats, strips, or flooring shall be used in all bathtub and shower floors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
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Based on [(observation) the licensee did not comply with the section cited above as three oiut of three bathrooms do not have a non-skid mat,] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/25/2026
Plan of Correction
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Administrator will add non skid mats to al shower araes by POC date.
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) and (record review)], the licensee did not comply with the section cited above in 3 out of 3 residents LIC622 was not propertly filled out, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2026
Plan of Correction
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Administrator will contract a professional qualified vendor to provide medication training for all staff to ensure medication information is correctly inputted in the LIC 622. The qualified vendors qualifications and credentials must be provided along with the date and time of the training and the staff's names and signatures who attended the training,
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Sandra Urena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2026


LIC809 (FAS) - (06/04)
Page: 5 of 14
Document Has Been Signed on 09/24/2026 05:11 PM - It Cannot Be Edited


Created By: Sandra Urena On 09/24/2026 at 03:54 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COTTAGES OF LAKE BALBOA 2, THE
FACILITY NUMBER: 197609868

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation), the licensee did not comply with the section cited above as the kitchen cabinets, drawers, dishwasher were observed in unhiginic condition, closet sliding door is in need of repair, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2026
Plan of Correction
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The Administrator will email pictures of the kitchen area after it as received a deep cleaning as specified in this citation, video of closet door repaired.
Type B
Section Cited
CCR
87307(d)(5)
Personal Accommodations and Services
(5) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation), the licensee did not comply with the section cited above, because the nightlights were not observed outsied the six bedrooms, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2026
Plan of Correction
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Administrator will install nightlights in all areas leanding from the bedrooms to the bathrooms.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Sandra Urena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2026


LIC809 (FAS) - (06/04)
Page: 6 of 14
Document Has Been Signed on 09/24/2026 05:11 PM - It Cannot Be Edited


Created By: Sandra Urena On 09/24/2026 at 03:54 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COTTAGES OF LAKE BALBOA 2, THE
FACILITY NUMBER: 197609868

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) , the licensee did not comply with the section cited above, because the RCFE Complaint poster (PUB475) was not posted per regulations, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2026
Plan of Correction
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Administrator will post the PUB 475 ina prominenet place in the common areas.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Sandra Urena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2026


LIC809 (FAS) - (06/04)
Page: 7 of 14
Document Has Been Signed on 09/24/2026 05:11 PM - It Cannot Be Edited


Created By: Sandra Urena On 09/24/2026 at 03:54 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COTTAGES OF LAKE BALBOA 2, THE
FACILITY NUMBER: 197609868

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) the licensee did not comply with the section cited above in 3 out of 3 pills were stored in weekly pill boxes, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2026
Plan of Correction
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Administrator will ensure immediatly that medications are not stored in the weekly medication pill boxes.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Sandra Urena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2026


LIC809 (FAS) - (06/04)
Page: 8 of 14
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: 09/24/2026
NARRATIVE
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MEDICATIONS: Medications review began at 2:35 p.m.; medications are centrally stored and locked in a cabinet in the kitchen area. Medications are labeled and checked for expiration dates. The medications are documented on the centrally stored medications and destruction record, however, the medications for three (3) out of three (3) residents do not list the START DATE of the medication, consequently, the LPA was not able to conduct a medication audit. For one (1) out of three (3) residents, it was observed that the LIC 622 had only one medication listed “Ondansetron”, however, when the LPA inspected the resident’s medication basket, the LPA observed that the following medications were not listed: Dorzolamide, and Latanoprost, Tylenol and Docusate. Furthermore, for (1) out of three (3) residents, it was observed that the daily medications were sorted in a weekly pill box, but the medication bottles were not in the resident’s medication basket. When the LPA brought this to the staff’s attention, the staff brought the medication bottles from different location outside the facility.

The LPA reviewed the following documents:
- LIC500 Personnel Report
- LIC9020 Client Roster
- Certificate of Liability of Insurance
Emergency Drill Logs- The facility recently admitted their first resident in 08/2026. The staff were advised to conduct the first drill as soon as possible.

The LPA spoke with the Administrator Justin Levi, on the phone and the Administrator was unavailable to sign the report instructed staff Aura Melgar to sign the report on their behalf.

Citations were issued. 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: 09/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026
LIC809 (FAS) - (06/04)
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