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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850544
Report Date: 06/18/2025
Date Signed: 06/18/2025 01:18:19 PM

Document Has Been Signed on 06/18/2025 01:18 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:LAKE BALBOA ASSISTED LIVINGFACILITY NUMBER:
195850544
ADMINISTRATOR/
DIRECTOR:		NALBADIAN, MANUSHFACILITY TYPE:
740
ADDRESS:16037 HART STREETTELEPHONE:
(323) 243-1928
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY: 6CENSUS: 0DATE:
06/18/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:26 AM
MET WITH:Manush NalbadianTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Sandra Urena conducted a Pre-licensing visit and met with the applicant... This is a new facility application for a Residential Facility for the Elderly (RCFE) for six (6) non-ambulatory residents; one (1) of which may be a bedridden resident(s). Waiver was granted for hospice care for six (6) residents. Fire Clearance was approved on 09/27/2024. Bedridden approved in bedroom #1.

At 9:30 a.m., the LPA, and the applicant toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility will be following Title 22 Regulations.

COMMON AREAS: The living room area is equipped with a television, and a fireplace which is operated with gas and is functional. The fireplace was covered and inaccessible to residents in care. There is a dedicated area for the posting of required documents at the entrance of the facility. Smoke and carbon monoxide alarms were tested and functional at the time of the visit. Medications will be stored in a locked cabinet in the kitchen area next to the refrigerator. The residents’ and staff files will be stored and locked in a cabinet located in the living room area. LAUNDRY: There is a laundry room equipped with washer and dryer; the room is accessible through the back yard area and has a door with a lock. Detergents and cleaning supplies will be stored in a locked in this room. FRONT ENTRANCE: Front entrance will require a ramp for accessibility to the facility.

Continues on LIC 809C...
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Sandra Urena
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2025
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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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: LAKE BALBOA ASSISTED LIVING
FACILITY NUMBER: 195850544
VISIT DATE: 06/18/2025
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KITCHEN: Kitchen knives are stored locked and inaccessible in a locked kitchen drawer. A seven-day supply of non-perishable food was available. The supply of dishes is adequate. Appliances in the kitchen were clean and all appeared functional. Kitchen cleaning supplies will be stored and locked under the kitchen sink. Hot water temperature was recorded at 130.6 degrees Fahrenheit. Trash cans have a tight-fitting lid. There were no pesticides or toxins stored near food, or preparation area. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. A fire extinguisher is located near the kitchen area; however, it was purchased in 2023 and was expired.

BEDROOMS: There are three (3) bedrooms for residents in care, and one bedroom for staff. The Applicant will send a revised Facility Sketch to CAB to floor plan to add the Staff Bedroom. All rooms are shared rooms. Room #1 is approved for one (1) bedridden resident. All bedrooms are cleared for non-ambulatory. All bedrooms have a ramp available to exit to the outdoor area. All bedrooms were supplied with all required bedding and linens. Bedroom #3 requires additional closet and drawer space. Bedroom #1 will require additional drawer space and reposition the bed to allow for more passage to the outdoor area. Bedroom #1 requires additional drawer space. There is sufficient lighting as well as closet and drawer space available.



BATHROOMS: There are three (3) full bathrooms, with shower area only and one-half bathroom. Bathrooms are equipped with toilets and shower grab bars, and non-skid mats. There are sufficient supplies of towels, paper goods and personal hygiene supplies. Hot water delivered was at 130.8 degrees Fahrenheit.

SURROUNDING GROUNDS/OUTDOOR AREA: The exterior passageways were clean. The patio is furnished with outdoor furniture for residents’ use, and shade is available. The building has a central entrance for residents and visitors. Right passageway of the front of the property was cleared by the LAFD as the emergency exit/passageway.



At the time of the visit the LPA observed one (1) ADU unit. The unit is identified by the address # 16035 and is located on the left-hand side of the front of the property/facility. The ADU unit will be separated from the main address by a fence and will not be accessible to residents in care. The Fire inspection did not include the ADU.

Continues on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Sandra Urena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
LIC809 (FAS) - (06/04)
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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: LAKE BALBOA ASSISTED LIVING
FACILITY NUMBER: 195850544
VISIT DATE: 06/18/2025
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Pre-Licensing is incomplete with deficiencies to be resolved by 07/10/2025. Follow up Pre-licensure LIC809 will be generated upon resolution.

· Front entrance will require a ramp for accessibility to the facility.


· Hot water temperature was recorded at 130.6 degrees Fahrenheit.
· A fire extinguisher is located near the kitchen area; however, it was purchased in 2023 and was expired.

· The Applicant will send a revised Facility Sketch to CAB to reflect the Staff Bedroom.


· Bedroom #3 requires additional closet and drawer space. Bedroom #1 will require additional drawer space and reposition the bed to allow for more passage to the outdoor area. Bedroom #1 requires additional drawer space.
· Night-light added to hallway.
  • Toilet Paper holders
  • Purchase hygiene items.

The applicant completed Component III orientation.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview was conducted and reviewed with the applicant. 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: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
LIC809 (FAS) - (06/04)
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