<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609865
Report Date: 09/13/2022
Date Signed: 09/13/2022 01:30:14 PM

Document Has Been Signed on 09/13/2022 01:30 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:
09/13/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Diana SoTIME COMPLETED:
11:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced Case Management visit to the facility in order to continue the Annual/Required visit that was conducted on 9/1/2022. Upon arrival LPA met with Diana So and explained the reason for the visit. LPA spoke with Justin Levi who stated Diana can sign in his place. This annual had a specific emphasis on infection control practices and procedures.

Common Areas:  These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit.

Surrounding Grounds (Outdoors): There was a shaded courtyard area with proper furniture for outdoor use to the left of the facility. There are no bodies of water on the premises. Facility shares a lot with Cottages of Lake Balboa 2 and Cottages of Lake Balboa 3. Main Office is located in the rear of the facility.
 

The LPA spoke with Diana regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to isolate each resident in their private room if the facility has a confirmed case of COVID-19. COVID-19 testing is conducted weekly if anyone shows any symptoms. The facility’s policies and procedures as it pertains to infection control are adequate at this time.
 
Exit interview conducted, report issued and sent via email.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2022
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 1