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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850334
Report Date: 12/23/2024
Date Signed: 12/23/2024 01:20:11 PM

Document Has Been Signed on 12/23/2024 01:20 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:BALBOA ASSISTED LIVING INCFACILITY NUMBER:
195850334
ADMINISTRATOR/
DIRECTOR:		HARUTUNYAN, ALLAFACILITY TYPE:
740
ADDRESS:7647 PASO ROBLES AVETELEPHONE:
(818) 434-9916
CITY:LAKE BALBOASTATE: CAZIP CODE:
91406
CAPACITY: 6CENSUS: 6DATE:
12/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Alla HarutunuanTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valeria Conway conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control #29-AS-20240429125818). The purpose of the visit is to issue citations for deficiencies observed during the initial complaint investigation unrelated to the complaint. During today’s visit, LPA met with Alla Harutunyan and the reason for the visit was explained.

During the course of the investigation, it was discovered 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 and R1 had a Peripherally Inserted Central Catheter (PICC) and was prescribed the antibiotic Daptomycin, which was administered by a home health nurse. However, based on record review facility did not obtain an exception request from the Department prior to accepting/retaining R1 who had a prohibited health condition. Additionally, record review reflected that facility did not conduct a pre-placement appraisal, Needs and service plan, and home health admission folder/records prior to R1’s admission to the facility. Administrator stated that they did not consider it necessary to evaluate R1 because R1 was not an elderly person, and the hospital the resident was coming from was located far from the facility.

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
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 12/23/2024 01:20 PM - It Cannot Be Edited


Created By: Valeria Conway On 12/23/2024 at 12:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
12/27/2024
Section Cited
CCR
87506(a)

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87506(a) Resident Records a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met as evidence by:
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Administrator agrees to write a statement of understanding on the importance of maintaning complete and current resident's records including a list of all required documents required before admission and submit them to LPA before POC due date
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Administrator did not comply with the above citation, as R1's records were not complete or current during complaint investigation which poses a potential health and safety risk to residents.
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Type A
12/27/2024
Section Cited
CCR87615(a)(4)

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87615(a)(4) Prohibited Health Conditions(a)Persons who require health services for or have a health condition including... (4)Staphylococcus aureus ("staph") infection or other serious infection.This requirement was not met as evidence by:
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Administrator agrees to write a statement of understanding regarding Prohibited Health Conditions, Also, a statement of understanding regarding on how to request an exemption from the department when need it. Administrator will submit them to LPA before due date.
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Based on interviews and record review, the licensee did not comply with the section cited above when they retained a resident with prohibited health conditions, which posed an immediate health and safety risk to residents 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 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


LIC809 (FAS) - (06/04)
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