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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609873
Report Date: 10/30/2023
Date Signed: 10/30/2023 02:51:33 PM


Document Has Been Signed on 10/30/2023 02:51 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, THEFACILITY NUMBER:
197609873
ADMINISTRATOR:JUSTIN LEVIFACILITY TYPE:
740
ADDRESS:6726 GAVIOTA AVETELEPHONE:
(747) 264-1116
CITY:LAKE BALBOASTATE: CAZIP CODE:
91406
CAPACITY:6CENSUS: 6DATE:
10/30/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Justin LeviTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control #29-AS-20220121164812). LPA met with Justin Levi and explained the reason for the visit. The purpose of this visit is to issue a citation for deficiencies observed during the complaint investigation which were not related to the complaint.

During today's visit, LPA conducted physical plant at approx 11:25am and observed medications for six (6) residents in care were pre-pored and out of their original containers for more than 24 hours. LPA observed the rest of resident medications to be securely stored in the Assistant Administrators office. LPA conducted medication audit. The Medication Administration Record (MAR) indicated that medications for the residents were administered as prescribed at this time. LPA also checked resident medications for expiration dates and instructions and the LPA uncovered minimal discrepancies. The LPA reviewed facility incident reports, and the LPA was unable to uncover incident reports as it related to known medication errors.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted/Citations issued/ Appeal Rights Discussed/ Copy of this report issued.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023
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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Document Has Been Signed on 10/30/2023 02:51 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/03/2023
Section Cited
CCR
87465(h)(5)

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87465(h)(5) Incidental Medical and Dental Care - Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
This requirement was not met as evidenced by:
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Licensee agreed to review section cited and provide a statement of understanding to CCL via email by EOD 11/03/2023.
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Based on observations and interview, LPA the licensee did not comply with the section cited above as (6) residents had medications pre-poured and out of their original containers for more than 24 hours which poses a potential health risk to persons in care.
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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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023
LIC809 (FAS) - (06/04)
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