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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609873
Report Date: 03/26/2022
Date Signed: 03/26/2022 03:28:05 PM

Document Has Been Signed on 03/26/2022 03:28 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:SAENZ, NICKFACILITY TYPE:
740
ADDRESS:6726 GAVIOTA AVETELEPHONE:
(747) 264-1116
CITY:LAKE BALBOASTATE: CAZIP CODE:
91406
CAPACITY: 6CENSUS: 4DATE:
03/26/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:32 PM
MET WITH:Benjie Binuya - CaregiverTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control #29-AS-20210715134128). LPA met with Benjie Binuya - Caregiver. Angelie De Leon - Resident Operation was contacted by phone and LPA explained the purpose of this report is to issue citation for deficiencies observed during the course of the complaint investigation.

During the complaint investigation of complaint #29-AS-20210715134128, Investigator Santana observed the following deficiencies:
1) Per review of the Licensing Information System (LIS) report, Staff #1 (S1) appears to be an uncleared adult. There was no record of anyone with this name among the facility’s personnel history. An immediate civil penalty is issued today for $500.

2) Resident #1 (R1) has half bedrails on bed, but it is unclear whether they are used solely for assistance with mobility, since they are engaged even when R1 sleeps.

3) Investigator Santana compared R1’s Appraisal Needs and Services Plan dated 05/10/2020 with the Plan dated 06/01/2021. It is evident the information from the former Plan was copied and applied to the latter Plan, rendering the 06/01/2021 Plan less than accurate. For example, the T7 compression fracture for which R1 was hospitalized sometime prior to 05/10/2020 would no longer be considered “recent” to 06/01/2021.
Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Immediate civil penalty $500 issued, exit interview conducted, copy of report and appeal rights issued via email to Licensee and Angelie De Leon - Resident Operation.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE: DATE: 03/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2022
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 3
Document Has Been Signed on 03/26/2022 03:28 PM - It Cannot Be Edited


Created By: Zabel Chochian On 03/26/2022 at 01:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COTTAGES OF LAKE BALBOA 3, THE
FACILITY NUMBER: 197609873

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/28/2022
Section Cited
CCR
87355(e)

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Criminal Record Clearance:(e)All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1)Obtain a California clearance or a criminal record exemption as required by the Department or
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Licensee will not allow S1 to work at facility until criminal record clearance obtained. Submit plan of correction to CCL by 3/28/2022.

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(f) Violation of Section 87355(e) shall result in an immediate assessment of civil penalties of one hundred dollars ($100) per violation per day for a maximum of five (5) days by the department.
This requirement is not met as evidenced by:
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 Based on records review, the licensee did not comply with the section cited above. S1 was not listed on the LIS, timecards and interviews indicated S1 worked at the facility without a criminal record clearance, which posed an immediate health and safety risk to residents in care.
Type B
04/01/2022
Section Cited
CCR87608(A)

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Postural Supports:(A)A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
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Licensee may submit copy of doctor's order for the half bed rails and indicate they will be used solely for the purpose of assistance with mobility or provide proof of coorection to regulation cited by other means after discussing with case LPA before due date. Submit correction by 4/1/2022 to CCL.
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Based on observation by Investigator Santana, the licensee did not comply with the section cited above. Half bed rails are engaged on R1’s bed at night, which posed a potiential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Desaree Perera
LICENSING EVALUATOR NAME:Zabel Chochian
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/26/2022 03:28 PM - It Cannot Be Edited


Created By: Zabel Chochian On 03/26/2022 at 02:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COTTAGES OF LAKE BALBOA 3, THE
FACILITY NUMBER: 197609873

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/01/2022
Section Cited
CCR
87463(a)

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Reappraisals:(a)The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition...
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Licensee to submit copy of R1’s current, accurate Needs and Services Plan, signed and dated by both licensee and R1 or R1’s representative. Submit to CCL by 4/1/2022.
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This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above. R1 Needs and Services Plan dated 06/01/2021 did not contain accurate, current information, which posed a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Desaree Perera
LICENSING EVALUATOR NAME:Zabel Chochian
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2022


LIC809 (FAS) - (06/04)
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