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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609873
Report Date: 09/09/2021
Date Signed: 09/09/2021 12:51:45 PM

Document Has Been Signed on 09/09/2021 12:51 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 3, THEFACILITY NUMBER:
197609873
ADMINISTRATOR:PANTELIC, PHILLIPFACILITY TYPE:
740
ADDRESS:6726 GAVIOTA AVETELEPHONE:
(747) 264-1116
CITY:LAKE BALBOASTATE: CAZIP CODE:
91406
CAPACITY: 6CENSUS: 4DATE:
09/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:56 AM
MET WITH:JUSTIN LEVITIME COMPLETED:
01:00 PM
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At 10:56 a.m., Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. LPA explained the reason for the visit to Administrator JUSTIN LEVI. This annual had a specific emphasis on infection control practices and procedures.

Between 10:56 a.m.- 11:30 a.m., 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.

OUTDOOR SPACE: At 10:56 a.m., LPA observed the front patio, which has a covered outdoor area for resident use. There is a gate on the side of the facility designated for an emergency exit. Passageways were free and clear from obstruction.

KITCHEN: At 10:57 a.m., 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. At 11:00 a.m., LPA observed staff preparing food in the kitchen. At 11:08 a.m., hot water measured at 105.2-degree Fahrenheit. Medications and first aid kits are located in a locked kitchen cabinet.

BEDROOMS: LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level.

RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. At 11:10 a.m., hot water measured at 117.8-degree Fahrenheit.

Continued on LIC 809-C.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2021
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 3, THE
FACILITY NUMBER: 197609873
VISIT DATE: 09/09/2021
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Continued from LIC 809.

COMMON AREAS: LPA observed common area to be relatively clean and properly furnished. LPA observed the fire extinguisher to be fully charged and last serviced on 12/29/2020.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station.

LPA observed a 30-day 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 designate a single isolation room if the facility has a confirmed case of COVID-19. The facility has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate.

Between 10:50 a.m. - 11:30 a.m., LPA conducted Infection Control mitigation module with Administrator.

No deficiencies were observed at this time. Exit interview conducted. Report issued and a copy of the report was provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021
LIC809 (FAS) - (06/04)
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