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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609873
Report Date: 09/13/2022
Date Signed: 09/13/2022 04:46:30 PM

Document Has Been Signed on 09/13/2022 04:46 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: 5DATE:
09/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Laura Gomez - Caregiver TIME COMPLETED:
12:30 PM
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At 11:00 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 Laura Gomez Caregiver. LPA spoke with Administrator Justin Levi over the phone who stated that caregiver Laura Gomez can sign for the report in his absence. This annual had a specific emphasis on infection control practices and procedures.

At approximately 11:30am,  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. Fire extinguishers were observed fully charged and last serviced in December of 2021.

LPA observed the kitchen/dining area. Knives are stored in a locked drawer to the right of the stove. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food.  Medications were observed stored in a locked cabinet to the left of the fridge. First aid kit was observed on the wall outside of the entry way of kitchen.

Restrooms were observed relatively clean, sanitary and in operating condition with grab bars and non-skid mats. Hot water measured between  115 - 120 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 11:38am, LPA observed residents resting in their bedrooms.

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. Laundry area located in the rear of the facility was observed inaccessible to residents at this time.
Continued on 809-C
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)
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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: 09/13/2022
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Continued from 809

Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use to the right of the facility. There are no bodies of water on the premises. Facility shares a lot with Cottages of Lake Balboa 1 and Cottages of Lake Balboa 2. Main Office is located in the rear of the facility.
 
The LPA spoke with Laura 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
LIC809 (FAS) - (06/04)
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