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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609873
Report Date: 08/29/2024
Date Signed: 08/29/2024 08:03:19 PM

Document Has Been Signed on 08/29/2024 08:03 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:COTTAGES OF LAKE BALBOA 3, THEFACILITY NUMBER:
197609873
ADMINISTRATOR/
DIRECTOR:
JUSTIN LEVIFACILITY TYPE:
740
ADDRESS:6726 GAVIOTA AVETELEPHONE:
(747) 264-1116
CITY:LAKE BALBOASTATE: CAZIP CODE:
91406
CAPACITY: 6CENSUS: 6DATE:
08/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:53 AM
MET WITH:Justin LeviTIME VISIT/
INSPECTION COMPLETED:
05:26 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Sandra Urena and Erica Mosley arrived at the facility unannounced at 11:53 a.m. to conduct a required annual inspection. The LPAs were greeted by staff and informed them of the reason for the visit. Administrator arrived about 30 minutes later.

The LPAs and the staff 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.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature of 71 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was fully charged and was last serviced on 01/09/2024. The LPAs observed required postings throughout the common space. The LPAs noticed that the Emergency Disaster Plan LIC 610E(Assignments) staff’s names need to be updated as some staff are no longer employed at the facility.

KITCHEN: Knives are locked in a kitchen drawer stored inaccessible to residents in care. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The hot water temperature measured at 113.0 degrees Fahrenheit. During the inspection at 12:41 p.m., the LPAs observed the bottom sink cabinet which contained the chemicals to be unlocked and chemicals accessible to residents in care. The cabinet was secured during the visit.

BEDROOMS: There are (6) resident bedrooms. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. At the time of the visit two bedrooms’ (Bedroom #2 and #3) exit door were obstructed by furniture. The furniture was removed during the visit. The LPAs observed and detected the smell of urine in bedroom #5, staff were instructed to change the bed linens.

There was a linen closet in the hallway with extra towels and linens.

Continues on LIC 809C ...

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COTTAGES OF LAKE BALBOA 3, THE
FACILITY NUMBER: 197609873
VISIT DATE: 08/29/2024
NARRATIVE
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BATHROOMS: The facility has three bathrooms. Two bathrooms (one shared and one private) were clean and sanitary and in operating condition with grab bars and non-skid surfaces. One shared bathroom’s toilet -between rooms #4 and #5 was observed to have dried feces- and a razor accessible to residents in care. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature measured in the hallway restroom at 113.0 degrees Fahrenheit.

OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. The washer and dryer are outside the facility. Detergent supplies are kept and locked in the laundry room.

RECORDS: Records review began at 1: 36 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate annual training. Four out of four staff files are missing a current CPR/First Aid Certificate, and the annual 20-hour training.

MEDICATIONS: Medications review began at 3:45 p.m.; medications are centrally stored and locked in a cabinet in the kitchen area. Medications were audited and counted for accuracy of dispensing the medications. Two out of three medications audited were not properly documented on the centrally stored medications and destruction record. During the physical plant inspection, the LPAs observed that the staff had pill boxes for each of the six residents. The pill boxes had medications sorted out for each day of the week.

INFECTION CONTROL: 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 designate a single isolation room if the facility has a confirmed case of COVID-19.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code.

.Citations were issued. Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/29/2024 08:03 PM - It Cannot Be Edited


Created By: Sandra Urena On 08/29/2024 at 05:02 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: 08/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above as cleaning solutions were observed unlcked in a cabinet under the sink, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2024
Plan of Correction
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Cleaning and desinfectatnts were loceked at the time of the visit.
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in thwo out of three medications were not dispensed correctly, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2024
Plan of Correction
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Administrator will contract a vendor to consucte training on how to fill out the Centrally stored medication form and dispense the medications.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Sandra Urena
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/29/2024 08:03 PM - It Cannot Be Edited


Created By: Sandra Urena On 08/29/2024 at 05:02 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: 08/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in one room it was detected a strong smell of urine, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2024
Plan of Correction
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Corrected on the day of the visit.
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in four staff out of four staff did not have CPR training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2024
Plan of Correction
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Administrator will provide proof of training by sending a copies of the CPR certificate.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Sandra Urena
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 08/29/2024 08:03 PM - It Cannot Be Edited


Created By: Sandra Urena On 08/29/2024 at 05:02 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: 08/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as four out of staff didnot have on file the 20 hours of annual training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/09/2024
Plan of Correction
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Administrator will send proof of training to LPA by the POC due date
Type B
Section Cited
CCR
87608(a)(5)(A)
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:
Deficient Practice Statement
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Based on observation and record review)], the licensee did not comply with the section cited above as one out of six residents bed had full bed rails without a doctor's order, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2024
Plan of Correction
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Administrator will email to LPA proof of the doctor's order for a full bed rail.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Sandra Urena
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024


LIC809 (FAS) - (06/04)
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