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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610476
Report Date: 02/14/2024
Date Signed: 02/14/2024 01:51:48 PM

Substantiated


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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/07/2024 and conducted by Evaluator Michael Cava
COMPLAINT CONTROL NUMBER: 31-AS-20240207114039
FACILITY NAME:BALBOA SENIOR LIVINGFACILITY NUMBER:
197610476
ADMINISTRATOR:ARMINE ERITSIANFACILITY TYPE:
740
ADDRESS:11661 BALBOA BLVDTELEPHONE:
(818) 571-5522
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:6CENSUS: 0DATE:
02/14/2024
UNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Armine Eritsian, Rosanna SargsyanTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff are not able to meet resident's needs due to inadequate staffing.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to investigate the above allegation. It was reported that Resident 1 (R1), who stayed at the facility on or about 01/23/24 until on or about 01/25/24, and or their family was unable to communicate with staff, therefore unable to meet R1's needs due to a language barrier. LPA met with staff, Rosanna Sargsyan and advised her of the complaint. The administrator, Armine Eritisian was notified shortly after. Today's investigation consisted of interviews with the administrator and staff, and a physical plant inspection.

Interviews with the administrator confirm that R1 stayed at the facility for approximately three days. R1's family found another facility suitable for their needs. It was also revealed that Staff 1's (S1) English was limitied, making it challenging for staff to communicate with a resident and their responsible party. S1 no longer works at the facility. Based on the information obtained, the allegation of staff unable needs to to inadequate staffing is Substantiated. Citation issued on the 9099D.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
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 3
Control Number 31-AS-20240207114039
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BALBOA SENIOR LIVING
FACILITY NUMBER: 197610476
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/21/2024
Section Cited
CCR
87411(a)
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Personnel Requirements - General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement was not met as evidenced by confirmation during investigation on 02/14/24. It was revealed that Staff 1's (S1)
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S1 no longer works at the facility. Moving forward, the licensee will insure that all staff hired will be sufficient in numbers and competetent enough to communicate with the resident and their families. As POC, the administrator will read this section of the regulation, and self certify, that they have
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English was limited, making it challenging for staff to communicate with a resident and their family.
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read and undeerstood this section of the regulations. Self certification is due to the licensing agency by 02/21/24.
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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: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/07/2024 and conducted by Evaluator Michael Cava
COMPLAINT CONTROL NUMBER: 31-AS-20240207114039

FACILITY NAME:BALBOA SENIOR LIVINGFACILITY NUMBER:
197610476
ADMINISTRATOR:ARMINE ERITSIANFACILITY TYPE:
740
ADDRESS:11661 BALBOA BLVDTELEPHONE:
(818) 571-5522
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:6CENSUS: 0DATE:
02/14/2024
UNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Armine Eritsian, Rosanna SargsyanTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff left resident in soiled diaper for an extended period of time.
Staff did not ensure resident was properly clothed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to investigate the above allegations. LPA met with staff, Rosanna Sargsyan and advised her of the complaint. The administrator, Armine Eritisian was notified shortly after. Today's investigation consisted of interviews with the administrator and staff, and a physical plant inspection.
In regards to both of the above allegations, it was reported that on or around 01/24/24, when Resident 1's (R1) family came to visit, R1 was observed in a soiled diaper, and not wearing any pants, but only covered with a light blanket. Family had to assist Staff 1 (S1) in changing R1's diaper. There were no witnesses identified to confirm these allegations. Only R1's family and staff were present. Interviews made with the administrator and staff deny the allegation. Current staff, Rosanna Sargsyan, is just recently hired and was not working at the facility at that time. According to the administrator, R1's diaper was just changed prior to family's arrival that morning. S1 no longer works at the facility. Based on the information obtained through interviews, it could not be proven that staff left R1 in their soiled diaper for a period of time and did not insure R1 was properly clothed. Therefore, the allegations are deemed Unsubstantiated at this time.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
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 3