<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850400
Report Date: 07/01/2024
Date Signed: 07/01/2024 04:56:39 PM


Document Has Been Signed on 07/01/2024 04:56 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:BALANCED LIVING BOARD AND CAREFACILITY NUMBER:
565850400
ADMINISTRATOR:AVETYAN, SMBATFACILITY TYPE:
740
ADDRESS:1430 CALLE MADRESELVATELEPHONE:
(626) 200-5821
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 1DATE:
07/01/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Alvard Galstyan - CaregiverTIME COMPLETED:
03:00 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) Valera Conway conducted an unannounced Case Management Deficiency visit in conjunction with an initial 10-day complaint visit (CC # 29-AS-20240625130611). Upon arrival, LPA was greeted by facility staff Alvard Galstyan. Staff Galstayan contacted facility Administrator/Licensee Representative Amaliya Santiago via phone. Administrator/Licensee Representative informed LPA that she, along with the other three (3) designated administrators are unable to be present during today’s visit and authorized facility staff Galstayan to sign and receive report. The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint.

During today's visit, LPA spoke with designated facility administrator Avetik Avetyan and requested to review the facility Personnel record (LIC 500) and/or copy of the staff schedule along with a copy of the Resident/Client Roster. Administrator stated that he intended to complete a staff schedule/LIC500 and the Resident/Client Roster, however, has not completed one at this time. Administrator agreed to complete all required forms and have it readily available for licensing review.

Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D).

A telephonic exit interview was conducted with facility's Licensee and Administrator. A hard copy of the report was provided. A copy of the report and appeal rights was issued.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria ConwayTELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2024
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 2


Document Has Been Signed on 07/01/2024 04:56 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: BALANCED LIVING BOARD AND CARE
FACILITY NUMBER: 565850400

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/15/2024
Section Cited
CCR
87208(a)(5)

1
2
3
4
5
6
7
87208(a)(5)(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall... Any significant changes in the plan of operation... (5) Staffing plan, qualifications and duties.This requirement is not met as evidenced by…
1
2
3
4
5
6
7
Administrator shall complete a LIC 500 and post it at the facility or have it readily available for when licensing department request it. LPA expects administrator to have updated LIC 500 before POC due date.
8
9
10
11
12
13
14
Based on observation, and interviews, licensee did not comply with the above section by not ensuring plan of operation documentation is being kept readily avaailable to licensing departments which poses a potential health, safety and personal rights risk to resident in care.
8
9
10
11
12
13
14
Administrator shall complete a resident roster form, post it at the facility or have it readily available for when licensing department request it. LPA expects administrator to have updated form before POC due date.
Type B
07/15/2024
Section Cited
CCR87508(b)

1
2
3
4
5
6
7
87508 Register of Residents (b) Registers of residents shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours... This requirement is not met as evidenced by…
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Valeria ConwayTELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2