<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610476
Report Date: 11/07/2023
Date Signed: 11/07/2023 01:19:21 PM

Document Has Been Signed on 11/07/2023 01:19 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:BALBOA SENIOR LIVINGFACILITY NUMBER:
197610476
ADMINISTRATOR:LUIZA YENGIBARYANFACILITY TYPE:
740
ADDRESS:11661 BALBOA BLVDTELEPHONE:
(818) 571-5522
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 0DATE:
11/07/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Luiza Yengibaryan & Vladsilav BlitshteynTIME COMPLETED:
01:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Leslie Ngo-Castaneda, Gina Saucedo and Huma Rahimi conducted an announced pre-licensing visit at 10:00 AM and met with the licensee Vladsilav Blitshteyn and administrator Luiza Yengibaryan. In addition to the pre-Licensing inspection, a component III power point presentation was also held. An application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on August 1, 2023. LPAs observed that no residents during the inspection.
A tour of the physical plant was initiated at approximately 11:25am and the following was observed:

With the assistance of the licensee and administrator, LPAs conducted a facility tour of both the inside and outside. This is a single-story property. The facility is a one-story building with seven (7) bedrooms and three (3) bathrooms. A fire clearance was approved on September 13, 2023, for six (6) non-ambulatory. One (1) can be used as ambulatory and one (1) bedridden for a total capacity of six (6) residents. The applicant is also requesting a hospice waiver to retain five (5) residents. All residents’ bedrooms were adequately furnished. The facility has a designated a live-in staff restroom and staff bedroom. Resident bathrooms have properly installed grab bars and shower has non-skid flooring. Hot water temperature for bathroom # 1 between room # 4 and 5 measured at 118.1ºF, and bathroom # 2 between room # 2 and #3 measured at 114.4 ºF during the visit. The facility has an adequate temperate of 73 ºF and 75 ºF.

The common areas were appropriately furnished these included the living and dining room area. The living room was equipped with couch, non-audible camera, a television, tables and chairs. The LPAs observed entertainment equipment and games for activities. The facility has a kitchen area that is equipped with a non-audible camera, refrigerator, microwave oven, and sink. The dining table is large enough to seat six (6) individuals.
Continue to LIC 809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2023
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: BALBOA SENIOR LIVING
FACILITY NUMBER: 197610476
VISIT DATE: 11/07/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The facility has a staff workstation that is in the kitchen where designated storage cabinet for residents and staff records are located in a lock cabinet. The first-aid kit is complete. The facility has adequate linen, water, and emergency kits. The linens were stored in the storage space located in the hallway.

LPAs observed a fireplace that is turned into an aquarium. The smoke alarms and carbon monoxide detector are dual and inter-connected. There is a fully charged fire extinguisher located in the kitchen area and both hallways. The hallways are well lighted and a night-light. Receipt shows that fire extinguisher was purchased on 11/01/2023 and LPAs advised the licensee to retain the receipt of the fire extinguisher identifying the purchase date to ensure the time frame for annual inspection.

There are six (6) bedrooms designated for resident use. All six rooms are designated for private use. Currently, room #3 is used as the model bedroom. Room #3 was equipped with bed, night-stand chair, dresser, bedding, bedbug covers and linen. Rooms #1, #2, #4, #5 and #6 were not completely furnished without a bed only at this time. Rooms were observed to have sufficient lighting and closet space. Per STD 850, Bedroom #1, #2, #4, #5 and #6 is ambulatory only. Bedrooms #3 is cleared for non-ambulatory for one bedridden only.

LPAs observed a washer and dryer in the laundry room within the kitchen with a closed and lock door. All chemicals, additional personal hygiene items were stored and locked in the laundry room. The medications are stored in a locked cabinet located in the kitchen. LPAs inspected the kitchen and observed gas stove and refrigerator to be clean and working. Knives and sharps are stored in a locked kitchen drawer.

The driveway, passageways and entrance to the home was clear of obstruction. All entry and exit doors have a functional auditory alert when the doors open. There is sufficient outdoor space with seating and a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises. Pursuant to Title 22, Division 6 of the CA Code of Regulations, the facility's physical environment appears to be compliant and ready for licensure. CAB will be advised, and a copy of this report provided. No health and safety hazard were noted during this visit. Licensee shall contact LPA once the first resident is admitted. Exit interview was conducted and a copy of report was issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2