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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609865
Report Date: 01/22/2024
Date Signed: 01/22/2024 03:43:22 PM

Document Has Been Signed on 01/22/2024 03:43 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: 3DATE:
01/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Angie De Leon - Assistant AdministratorTIME COMPLETED:
04:00 PM
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 - Incident Visit to follow up on a SOC 341 01-17-2024.  LPA met with Angie De Leon and explained the reason for the visit.

 On 01/17/2024, the department reviewed a SOC 341,  for Resident #1 (R1) along with a copy which indicated Staff #1(S1), allegedly took their shirt off in R1's room along with almost taking their pants off. S1 has since been placed on administrative leave pending a full investigation.

At approx 2:30 p.m., LPA conducted physical plant, interviewed staff, residents as well as reviewed and obtained pertinent documents relevant to the investigation. LPA did not observe any immediate or potential health and safety concerns at this time.

The LPA has determined further investigation is needed and will return at a later date to complete the investigation if warranted.

Exit interview conducted and copy of report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2024
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