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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609865
Report Date: 09/01/2022
Date Signed: 09/01/2022 12:05:22 PM

Document Has Been Signed on 09/01/2022 12:05 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:COTTAGES OF LAKE BALBOA 1, THEFACILITY NUMBER:
197609865
ADMINISTRATOR:LEVI, JUSTINFACILITY TYPE:
740
ADDRESS:6724 GAVIOTA AVETELEPHONE:
(747) 264-1004
CITY:LAKE BALBOASTATE: CAZIP CODE:
91406
CAPACITY: 6CENSUS: 5DATE:
09/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Romulo Baterina JrTIME COMPLETED:
09:30 AM
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At 10:30 a.m., Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. LPA was greeted and screened by staff Romulo Baterina Jr. LPA spoke with Administrator Justin Levi over the phone who stated that caregiver Romulo Baterina Jr. can sign for the report in his absence. This annual had a specific emphasis on infection control practices and procedures.

At approximately 8:30am, LPA 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.

LPA observed the kitchen/dining area. Knives are stored in a locked cabinet. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Medications and first aid kits were observed located in a locked kitchen cabinet.

Restrooms were observed relatively clean, sanitary and in operating condition with grab bars and non-skid mats. Hot water measured at 115 degrees Fahrenheit.

LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. At 9am, LPA observed residents resting in their bedrooms.

Due to an urgent matter at the Regional office, LPA will need to return at a later date to continue the visit.

Exit interview conducted. Report issued and sent to Administrator via email.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2022
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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