197609873-9-14-2023-29-AS-BBAI-CVNUCD-20230914152747

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609873
Report Date: 09/14/2023
Date Signed: 09/14/2023 03:28:20 PM

Document Has Been Signed on 09/14/2023 03:28 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:	COTTAGES OF LAKE BALBOA 3, THE		FACILITY NUMBER:	197609873
ADMINISTRATOR:	SAENZ, NICK		FACILITY TYPE:	740
ADDRESS:	6726 GAVIOTA AVE		TELEPHONE:	(747) 264-1116
CITY:	LAKE BALBOA	STATE: CA	ZIP CODE:	91406
CAPACITY:	6	CENSUS: 4	DATE:	09/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Justin Levi - Administrator		TIME COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit at 12:30pm. Upon arrival LPA met with Administrator Justin Levi, and explained the reason for the visit. The LPA 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. The LPA began the inspection in the kitchen/food service area. LPA observed knives and sharp objects stored in a locked drawer to the right of the stove. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. LPA inspected the common areas throughout the facility inside and out. All areas have been appropriately furnished. The common areas were observed to be properly furnished and relatively clean at the of the visit. LPA observed appropriate signage regarding infection control posted throughout the facility. LPA observed sanitizer readily available in areas with high touch surfaces. Dining room and living room furniture was observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detectors were operational at the time of the visit. Fire extinguishers were observed throughout the facility, fully charged and were last serviced Jan, 01, 2023. At approximately 12:30pm LPA inspected all six (6) resident bedrooms. The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed all bathrooms were clean, properly supplied and had functional fixtures. The hot water was measured in each bathroom within 105 - 120 degrees Fahrenheit. Resident bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COTTAGES OF LAKE BALBOA 3, THE	FACILITY NUMBER: 197609873
	VISIT DATE: 09/14/2023

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Surrounding Grounds (Outdoors): There was a shaded courtyard area with proper furniture for outdoor use to the left of the facility. There are no bodies of water on the premises. Facility shares a lot with Cottages of Lake Balboa 1 and Cottages of Lake Balboa 2. Main Office is located in the rear of the facility.

Records review began at 01:30 pm, four (4) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Four (4) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were observed to be in order at this time.

Medications review began at approximately 2:00pm The medications are centrally stored in the main office located at the rear of the property, inaccessible to residents in care. Medications are properly documented on the centrally stored medications and destruction record.

Infection Control: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of a communicable disease. 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 each resident bedroom as a single isolation rooms if the facility has a confirmed case of a communicable disease. The facility’s policies and procedures as it pertains to infection control are adequate at this time.

Between 12:30pm - 01:30pm the LPA interviewed two (2) staff members and three (3) residents.

LPA obtained the following documents - Census, Staff schedule, Emergency Disaster plan and updated Limited Liability insurance.

Exit interview conducted and copy of report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2