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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850334
Report Date: 12/23/2024
Date Signed: 12/23/2024 01:18:59 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/29/2024 and conducted by Evaluator Valeria Conway
COMPLAINT CONTROL NUMBER: 29-AS-20240429125818
FACILITY NAME:BALBOA ASSISTED LIVING INCFACILITY NUMBER:
195850334
ADMINISTRATOR:HARUTUNYAN, ALLAFACILITY TYPE:
740
ADDRESS:7647 PASO ROBLES AVETELEPHONE:
(818) 434-9916
CITY:LAKE BALBOASTATE: CAZIP CODE:
91406
CAPACITY:6CENSUS: 6DATE:
12/23/2024
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Alla HarutunyanTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff did not ensure that resident’s medication was refilled in a timely manner
Unlawful eviction
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Valeria Conway conducted a subsequent complaint visit to the facility above to deliver final findings of the complaint allegations. At 12:15 P.M. LPA met with Alla Harutunyan, Administrator and explained the purpose of the visit.

LPAs Conway and Dulek conducted the initial 10-day visit on 05/07/2024. During the visit, LPAs conducted a tour of the physical plant at 11:10 A.M. Additionally, LPAs conducted interviews with Administrator, residents and potential witnesses on 05/01/2024, 05/07/2024 and 11/15/2024 and obtained records pertinent to the investigation at 12:30 P.M.

Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 29-AS-20240429125818
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: BALBOA ASSISTED LIVING INC
FACILITY NUMBER: 195850334
VISIT DATE: 12/23/2024
NARRATIVE
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Continued on LIC 9099-C

Regarding allegation “Staff did not ensure that resident’s medication was refilled in a timely manner,” it was alleged that facility staff did not order Resident #1’s (R1) antibiotic Daptomycin medication timely. Information gathered during the course of the investigation reflected that Resident #1 (R1) was admitted to facility on 04/19/2024, following discharge from a medical center where they were treated for a bone infection. Upon admission, R1 had a Peripherally Inserted Central Catheter (PICC) and was prescribed the antibiotic Daptomycin, which was to be administered daily by an external Home Health (HH) nurse which continued until 4/25/2024. According to R1, on 04/25/2024, facility staff informed them that their supply of antibiotics was running low. However, when the HH nurse arrived the following day, 04/26/2024, to administer the antibiotic, it was discovered that the supply had run out. The HH nurse immediately advised the facility administrator, to transport R1 to the hospital to ensure they receive their daily dose. Records indicate that the facility logs prescribed medications for residents in care on the centrally stored medication and destruction record to log (LIC 622). However, Daptomycin was not recorded on R1’s LIC 622. Facility administrator stated that since the medication was administered by an external HH nurse rather than facility staff, it had not been recorded on the LIC 622. The facility has been storing the antibiotics for R1 but tracking the medication had not been documented because R1 was receiving HH services. Administrator further stated that R1’s family was expected to refill the antibiotic prescription accordingly and that the HH nurse had been informed about the low supply; however, administrator did not have any supportive documents to provide regarding this agreement. Administrator also could not provide LPAs with HH records pertaining to R1. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that staff did not ensure that resident’s medication was refilled in a timely manner. Therefore, the above allegation “Staff did not ensure that resident’s medication was refilled in a timely manner” is deemed SUBSTANTIATED at this time.

Continued on LIC 9099-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20240429125818
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: BALBOA ASSISTED LIVING INC
FACILITY NUMBER: 195850334
VISIT DATE: 12/23/2024
NARRATIVE
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Continued on LIC 9099-C

Regarding allegation unlawful eviction. It was alleged that administrator unlawfully evicted R1 by refusing to allow R1 to return to the facility after hospitalization. It was further reported that when R1’s family attempted to arrange R1’s return back to the facility on 04/29/2024, and they were informed that the facility could no longer meet R1’s needs. Information gathered during the course of the investigation reflected that R1 was admitted to the hospital due to the facility’s failure to obtained prescribed medication timely. However, when R1 was ready to be discharged from the hospital, the administrator informed that the facility could no longer accept the resident due to R1 needing a higher level of care. Therefore, R1 was left with no alternative place to go and was presented with only two options, being dropped off at the nearest homeless shelter or to seek accommodation with a family member. Additional information gathered, also reflected that staff did not conduct an initial pre-placement appraisal nor a reappraisal prior to hospital discharge before determining the resident needed a higher level of care. Moreover, R1 was also not issued a proper eviction notice. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that R1 was unlawful evicted. Therefore, the above allegation “Unlawful eviction” is deemed SUBSTANTIATED at this time.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20240429125818
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: BALBOA ASSISTED LIVING INC
FACILITY NUMBER: 195850334
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/23/2024
Section Cited
CCR
87465(a)(1)
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87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility...(1) The licensee shall arrange, or assist in arranging...to the conditions and needs of residents. This requirement is not met as evidenced by…
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Administrator will ensure that before admission, residents will have a pre-appraisal conducted and an evaluation of each resident's condition assessed. At this time no POC is due.
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Based on interviews and records reviewed the licensee did not comply with the section cited above by not having a care plan prior to resident's arrival which poses an immediate health and safety rise for the residents in care.
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Type A
01/06/2025
Section Cited
CCR
87224(a)(4)
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87224(a)(4) Eviction Procedures (a)The licensee may evict a resident for one or more of the...Thirty (30) days written notice...(4)If, after admission, it is determined that the resident has a need not previously identified...This requirement is not met as evidenced by…
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Administrator will provide a statement of understanding regarging eviction process to LPA before POC due date.
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Based on interviews and record review, the administrator did not ensure that they provided R1 and/or their responsible person with a proper eviction notice and did not get prior approval of eviction from licensing, which posed an immediate health and safety risk to resident(s) 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.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4