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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850334
Report Date: 01/26/2026
Date Signed: 01/26/2026 02:12:04 PM

Document Has Been Signed on 01/26/2026 02:12 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:
01/26/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:37 AM
MET WITH:Alla HarutunyanTIME VISIT/
INSPECTION COMPLETED:
02:18 PM
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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct the required annual inspection. The LPA was greeted by staff. Staff contacted the Administrator and informed them of the visit. The Administrator Alla Harutunyan arrived shortly thereafter and the LPA explained the reason for the visit.

The LPA and the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature of 76 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was fully charged and was last serviced 005/29/2025. The LPA observed required postings by the foyer of the front door. The facility has a designated washer and dryer room which was observed to be locked at the time of the visit.

KITCHEN: Knives and cleaning supplies are stored inaccessible to residents in care. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The hot water temperature measured at 113.2 degrees Fahrenheit.

BEDROOMS: Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are four (4) designated residents’ rooms and one staff room. There was a linen closet in the hallway with extra towels and linens.

Continues LIC809C...

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Sandra Urena
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2026
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 3
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: BALBOA ASSISTED LIVING INC
FACILITY NUMBER: 195850334
VISIT DATE: 01/26/2026
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BATHROOMS: Bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature measured in the hallway restroom at 113.2 degrees Fahrenheit.

OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate for client use and is single-latched. No bodies of water were noted. The facility has a detached garage, which at the time of the visit is being converted into an ADU. Once the ADU is completed the Administrator will request an additional fire inspection from the Los Angeles Fire Department (LAFD) to ensure that the facility continues to meet LAFD regulations as they pertain to the facility. The Administrator will add a ramp with rails to the front of the facility to provide access to the residents in care to the side of the facility’s additional outdoor shaded area, due to the construction of the ADU, which is restricting access to the previous designated outdoor shaded area. The Administrator will ensure that all staff and residents do not use as an exit room’s #3 and room’s # 1 backdoor to gain access to the side outdoor area. A fence will need to be added to the side outdoor area to prevent residents from gaining access to the ADU construction area. Once the ADU is completed, the Licensee will ensure that a fence is erected from the ADU wall to the side of the facility wall to ensure that ADU tenants do not have access to the facility.


RECORDS: Records review began at 11:30 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.
MEDICATIONS: Medications review began at 12:45 p.m.; medications are centrally stored and locked in a file cabinet in the dining room area; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.
The LPA reviewed the following documents:
- LIC500 Personnel Report
- LIC9020 Client Roster
- Emergency Drills
- Liability Insurance
Administrator will email the LPA once the ADU is completed and approved by the city, so that a follow up visit is conducted.
Exit interview conducted. A copy of the report was issued.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Sandra Urena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2026
LIC809 (FAS) - (06/04)
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