300606338-3-14-2025-22-AS-LMOA-DF86PK-20250328205915

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 300606338
Report Date: 03/14/2025
Date Signed: 03/14/2025 02:39:44 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/04/2025 and conducted by Evaluator Claudia Gutierrez

COMPLAINT CONTROL NUMBER: 22-AS-20250304115058

FACILITY NAME:	BALBOA ISLAND BOARD & CARE		FACILITY NUMBER:	300606338
ADMINISTRATOR:	BARTON, CYNTHIA G.		FACILITY TYPE:	740
ADDRESS:	300 APOLENA		TELEPHONE:	(949) 673-8589
CITY:	BALBOA ISLAND	STATE: CA	ZIP CODE:	92662
CAPACITY:	4	CENSUS: 2	DATE:	03/14/2025
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Cynthia Barton		TIME COMPLETED:	02:55 PM

ALLEGATION(S):

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Licensee is smoking inside the facility
Licensee does not treat residents with dignity or respect

INVESTIGATION FINDINGS:

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An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegations mentioned above. LPA met with Administrator (AD) Cynthia Burton.

Interviews were conducted with facility residents, Staff 1 (S1), and Licensee regarding allegation Licensee is smoking inside the facility. During their interview, one of two facility residents denied having any knowledge of anyone smoking inside the facility, including Licensee and stated they do not like smoke. One of two residents was unable to confirm or deny allegation. During their interview, S1 denied Licensee, staff, or any other individual smoking inside the facility. Licensee also denied personally smoking inside of the facility and also denied any other staff smoke inside the facility. During today’s visit, LPA conducted a tour of the facility and did not observe smoke or anyone smoking inside, and facility scent was odorless. (Cont. LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20250304115058

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BALBOA ISLAND BOARD & CARE	FACILITY NUMBER: 300606338
	VISIT DATE: 03/14/2025

NARRATIVE

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Interviews were conducted with facility residents, Staff 1 (S1), and Licensee regarding allegation Licensee does not treat residents with dignity or respect. During their interview, one of two facility residents stated they are treated well by staff and they enjoy the tranquility at the facility. One of two residents could not confirm or deny allegation. During their interview, S1 denied Licensee does not treat residents with dignity or respect. Per S1, Licensee and staff treat facility residents well. Licensee also denied not treating resident with dignity or respect and stated they and staff treat residents well.

Due to conflicting information received during interviews conducted, LPA is unable to determine if Licensee is smoking inside the facility or if Licensee does not treat residents with dignity or respect. Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore at this time the above allegations are unsubstantiated.

An exit interview was conducted and copy of this report was provided at the end of the inspection.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/04/2025 and conducted by Evaluator Claudia Gutierrez

COMPLAINT CONTROL NUMBER: 22-AS-20250304115058

FACILITY NAME:	BALBOA ISLAND BOARD & CARE		FACILITY NUMBER:	300606338
ADMINISTRATOR:	BARTON, CYNTHIA G.		FACILITY TYPE:	740
ADDRESS:	300 APOLENA		TELEPHONE:	(949) 673-8589
CITY:	BALBOA ISLAND	STATE: CA	ZIP CODE:	92662
CAPACITY:	4	CENSUS: 2	DATE:	03/14/2025
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Cynthia Barton		TIME COMPLETED:	02:55 PM

ALLEGATION(S):

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Licensee does not ensure that staff are TB tested

INVESTIGATION FINDINGS:

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An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegation mentioned above. LPA met with Administrator (AD) Cynthia Burton.

During today’s visit, LPA obtained and reviewed three of three facility staff files. Three of three staff files were observed to include negative TB test results.

The Department has investigated the complaint alleging Licensee does not ensure that staff are TB tested. After record review of staff files, We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted and a copy of this report was provided at the end of the inspection.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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