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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610476
Report Date: 11/14/2024
Date Signed: 11/14/2024 11:51:38 AM

Document Has Been Signed on 11/14/2024 11:51 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
197610476
ADMINISTRATOR/
DIRECTOR:		RUZANNA SAKIASSYANFACILITY TYPE:
740
ADDRESS:11661 BALBOA BLVDTELEPHONE:
(818) 571-5522
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 3DATE:
11/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Ruzanna Sargsyan, Mario OchoaTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with staff, Rusanna Sargsyan, and explained the reason for the visit. The administrator, Mario Ochoa, joined shortly after.

At approximately 9:00am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms and carbon monoxide are dual and interconnected. There are two fire extinguishers. One is located in the kitchen, and the other is located at the hallway by resident room #6.

Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. LPA did no observe any cleaning supplies out and accessible in the kitchen.

Bedrooms: There are seven (7) bedrooms. Six (6) of the bedrooms designated for residents' use are private. One (1) room is designated for staff. The bedrooms designated for the residents use were observed to be properly furnished with appropriate beddings and linens with sufficient lighting.

Bathrooms: There are three (3) bathrooms designated for the residents' use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured between 109 and 114 degrees Fahrenheit. No cleaning supplies were observed in either bathrooms during the day of the inspection.

Common Areas: These included the living room and dining area. The living room was furnished with two couches, a recliner and a television. The dining room, located adjacent to the living room has a table large enough to seat up to six (6) residents. Living room and dining room furniture ere in good repair. Floors were mopped and clean. Exits and passageways were clear of any obstruction.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
VISIT DATE: 11/14/2024
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Surrounding Grounds: The front and back yards were free of obstruction. There was furniture in the backyard appropriate for outdoor use. There is sufficient yard space in the backyard to hold outdoor activities. There is no swimming pool or any other bodies of water. There is a storage that is observed to be locked. Exterior gates are only locked from the outside of the property. It is unlocked from the inside making it accessible for exit.

Laundry area: The laundry area is by the kitchen. Detergents and cleaning agents were locked.

Staff Workstation/Office: There is a staff workstation by the kitchen where resident and staff records are kept in a filing cabinet.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medications are stored locked in a kitchen cabinet. Medication and Medication Records were reviewed for proper storage and documentation.

Garage: The garage is attached to the building. Entry is from either outside from the backyard, or internally, by room #6. Garage is used to store supplies. It was locked during the annual.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC809 (FAS) - (06/04)
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