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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609873
Report Date: 10/16/2023
Date Signed: 10/16/2023 11:42:20 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/01/2021 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20211101125640
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:
10/16/2023
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Justin LveiTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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9
 Staff is not assisting the resident with managed incontinence.
INVESTIGATION FINDINGS:
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9
10
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12
13
**This report supersedes report issued on 06/19/2023**
Licensing Program Analyst (LPA) Brian Balisi, conducted an unannounced subsequent complaint visit to issue amended findings for the above listed complaint allegation. Upon arrival LPA met with Administrator Justin Levi and explained the reason for the visit.

On 11/02/2021 between 9:52am - 5:05pm, LPA Kelly Dulek conducted the initial complaint investigation. During that visit, LPA conducted physical plant, interviewed two (2) residents and three (3) staff, as well as reviewed pertinent documents relevant to the investigation. On 06/09/2023 at approximately 12:30pm, LPA conducted physical plant, interviewed four (4) staff, three (3) residents and their responsible parties, as well as reviewed and obtained copies of pertinent documentation relevant to the investigation. On 06/19/2023 LPA conducted physical plant and interviewed two (2) staff.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023
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-20211101125640
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/16/2023
NARRATIVE
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Continued from 9099

It was reported that staff is not assisting Resident # 1 (R1) with managed incontinence, as it was alleged that staff did not change R1 in a timely manner. Interviews and records review revealed that there were at least two (2) occasions when R1 was not changed in a timely manner. The facility administrator was notified by R1’s home health that R1 was observed to have wet sheets on 02/17/2020 and 02/18/2020. Interviews reflected that there was an evening where R1 in November 2021, where R1 was left in a soiled diaper for an extended period of time. Interviews also reflected that R1 preferred only certain caregivers assist and refused services until those caregivers were available. Moreover, it was revealed that R1 had an agreement that the caregiver’s of R1’s preference would assist with R1’s incontinent needs at 10:30am. R1 preferred staff to finish assisting other residents and complete their morning routine prior to assisting R1 due to liked staff to take their time assisting R1 which would last approximately 30 minutes to one (1) hour. Interviews conducted with other residents reflected that they had no concerns with incontinent care needs and staff routinely assisted residents every two (2) hours, or as needed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023
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
CCLD Regional Office, 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
11/01/2021 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20211101125640

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:
10/16/2023
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Justin LeviTIME COMPLETED:
11:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff is not able to meet the needs of the resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
This report supersedes report issued on 06/19/2023.
Licensing Program Analyst (LPA) Brian Balisi, conducted an unannounced subsequent complaint visit to issue amended findings for the above listed complaint allegation. Upon arrival LPA met with Administrator Justin Levi and explained the reason for the visit.

On 11/02/2021 between 9:52am - 5:05pm, LPA Kelly Dulek conducted the initial complaint investigation. During that visit, LPA conducted physical plant, interviewed two (2) residents and three (3) staff, as well as reviewed pertinent documents relevant to the investigation. On 06/09/2023 at approximately 12:30pm, LPA conducted physical plant, interviewed four (4) staff, three (3) residents and their responsible parties, as well as reviewed and obtained copies of pertinent documentation relevant to the investigation. On 06/19/2023 LPA conducted physical plant and interviewed two (2) staff.

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023
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-20211101125640
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/16/2023
NARRATIVE
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Continued from 9099

It was reported that staff is not able to meet the needs of R1, as it was alleged that there was not enough staff scheduled to assist R1 during the NOC shift. Interviews conducted and records reviewed reflected that during the time the complaint was received facility staffing was as follows: two (2) staff during the morning shift, two (2) staff during the afternoon/evening shift and one (1) staff during the NOC shift. Records further reflected that during the time of the complaint, R1 required assistance by two (2) caregivers. Therefore, based on information gathered there is sufficient evidence to determine that the facility did not have sufficient staffing to meet resident care needs during the NOC shift. Therefore, the above allegation is deemed Substantiated at this time.

The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20211101125640
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/20/2023
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... of adequate services.
This requirement was not met as evidenced by:
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Licensee has agreed review section cited and to write a Statement of Understanding and send to CCL via email by 10/20/23.
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Based on interviews and record review, the licensee did not comply with the regulation cited above in that staffing was not sufficient in numbers to provide needed services to R1 who required 2 person assist which poses a potential health, safety or personal rights 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.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5