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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609873
Report Date: 02/17/2023
Date Signed: 02/17/2023 03:47:28 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/12/2022 and conducted by Evaluator Christine Yee
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20221212110110
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:
02/17/2023
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Justin Levi, LicenseeTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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1. Staff did not provide an admissions agreement to resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst(LPA) Christine Yee conducted an unannounced subsequent complaint visit to conduct additional interviews and to deliver the findings of the investigation and met with Justin Levi, Licensee. The reason for today's visit was explained.

An initial unannounced complaint visit was conducted on 12/16/22 by LPA Yee from 8:10am - 11:00am. During the inital visit, LPA Yee collected the Admission Agreements for Resident #1, Resident #2 and conducted face to face interviews with Licensees, David Ebrami and Justin Levi and Resident #2. Resident #1 was not available for an interview.

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 29-AS-20221212110110
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COTTAGES OF LAKE BALBOA 3, THE
FACILITY NUMBER: 197609873
VISIT DATE: 02/17/2023
NARRATIVE
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LPA Yee also made attempts to interview witnesses telephonically and was unsuccessful. LPA Yee determined that further investigation was needed.

On 1/5/23, LPA Yee was able to reach Resident #1 to conduct a telephone interview.

On today's visit, LPA Yee conducted another interview with Justin Levi at 9:25am to clarify information provided on previous interviews regarding the facility's practice of notification to the residents about increases to their daily rent. Per information obtained from the Licensee, the facility provides all residents with a copy of the Admission Agreement when they first move in. The facility does not issue a new Admission Agreement or create an addendum to the agreement when there is a change in the rental rate. When there is a rate increase, a letter is sent out or given to the resident 60 days before implementation of the new rate and the resident is then billed at the new rate.

Per review of Resident #1's file, the copy of the Admission Agreement on file for Resident #1 was between Resident #1 and the previous owner and it was never updated when the facility was licensed on 9/13/2019. Resident #1 did not and does not have a valid Admission Agreement with the new entity identified as Cottages at Lake Balboa 3. Based on this information, Resident was never provided with a valid Admission Agreement, therefore Allegation #1 is substantiated.


Deficiencies were cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

Exit interview was conducted with Angelie De Leon and a copy of this report was provided and Appeals Rights were discussed.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/12/2022 and conducted by Evaluator Christine Yee
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20221212110110

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:
02/17/2023
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Justin Levi, LicenseeTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
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7
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9
2. Staff did not provide rate of services on admissions agreement to residents in care.
INVESTIGATION FINDINGS:
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5
6
7
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9
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13
Licensing Program Analyst(LPA) Christine Yee conducted an unannounced subsequent complaint visit to conduct additional interviews and to deliver the findings of the investigation and met with Justin Levi, Licensee. The reason for today's visit was explained.

An initial unannounced complaint visit was conducted on 12/16/22 by LPA Yee from 8:10am - 11:00am. During the inital visit, LPA Yee collected the Admission Agreements for Resident #1, Resident #2 and conducted face to face interviews with Licensees, David Ebrami and Justin Levi and Resident #2. Resident #1 was not available for an interview.

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20221212110110
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COTTAGES OF LAKE BALBOA 3, THE
FACILITY NUMBER: 197609873
VISIT DATE: 02/17/2023
NARRATIVE
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LPA Yee also made attempts to interview witnesses telephonically and was unsuccessful. LPA Yee determined that further investigation was needed.

On 1/5/23, LPA Yee was able to reach Resident #1 to conduct a telephone interview.

On today's visit, LPA Yee conducted another interview with Justin Levi at 9:25am to clarify information provided on previous interviews regarding the facility's practice of notification to the residents about increases to their daily rent. Per information obtained, the facility provides the residents and their responsible parties a letter of notification about the rent increases 60 days prior to implementation. Resident #1 was notified via letter dated 4/12/22 that the new daily rental rate would go into effect on 7/1/22. The facility does not generate a new Admission Agreement or complete an addendum to the admission agreement to reflect the increase in the daily rate. Instead the facility bills the resident at the new daily rate by the number of dates in the month. Per interviews conducted with the Licensees, the facility rate is a flat rate and is inclusive of all basic services and care, such as bathing, medication administration, diaper changes, laundry services and meals. Additional service rates are listed in the initial admission agreement signed with the previous ownership, such as the hourly rate charged for transportation for medical visits, cable services and third party services

Based on the investigation, the allegation that Staff did not provide rate of services on admissions agreement to residents in care is Unsubstantiated.


Exit interview was conducted with Angelie De Leon, Resident Operations since Justin Levi left during the visit and a copy of this report was provided.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20221212110110
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 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: 02/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/24/2023
Section Cited
CCR
87507(a)
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Admission Agreement: (a)The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any.
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The Licensee will review all residents file to ensure that there is a completed Admission Agreement in their file. Licensee will submit a written statement indicating that all resident files have been reviewed
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This requirement was not met as evidenced by: The facility failed to complete an Admission Agreement for Resident #1.
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and all files contain a completed Admission Agreement by 2/24/23
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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.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5