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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300606338
Report Date: 02/24/2025
Date Signed: 02/24/2025 11:36:05 AM

Document Has Been Signed on 02/24/2025 11:36 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:BALBOA ISLAND BOARD & CAREFACILITY NUMBER:
300606338
ADMINISTRATOR/
DIRECTOR:		BARTON, CYNTHIA G.FACILITY TYPE:
740
ADDRESS:300 APOLENATELEPHONE:
(949) 673-8589
CITY:BALBOA ISLANDSTATE: CAZIP CODE:
92662
CAPACITY: 4CENSUS: 2DATE:
02/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:04 AM
MET WITH:Cyntia BartonTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
NARRATIVE
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On February 24th, 2025 Licensing Program Analyst (LPA) William Vanegas made an unannounced inspection for the purposes of an annual inspection. Upon arrival LPA Vanegas was greeted and granted entry to the facility by Administrator (AD) Cynthia Barton. LPA Vanegas made the following observations

This is a one storied home with three bedrooms one of which is a staff room and two of which are resident rooms and one of which is a staff room along with two bathrooms both accessible to residents in care. LPA Vanegas observed kitchen area to be clean and free of debris. LPA Vanegas observed a two day supply of perishable food and a 7 day supply of non perishable food.

LPA Vanegas observed resident bathrooms to be clean and clear of debris. Resident bathrooms were observed to have all the required furnishings such as grab bars, shower chair, and slip resistant flooring. Water faucets and toilets tested to be operational and water tested between 113.6-116.3 degrees.

LPA Vanegas observed resident rooms to be clean and have no obstructions blocking the doorways. Bedrooms were observed to have all required furnishings such as a lamp, chair, chest drawers, and a bed with clean linens in good repair meaning no strains or tears. LPA Vanegas did not observe a PUB475 (see something say something) Sign of the proper dimensions posted on the entrance of the facility a technical violation was given on today's date.

LPA Vanegas did not observe an emergency disaster plan available for review nor did LPA Vanegas observe and infection control plan available for review. A deficiency was cited on today's date. Smoke and carbon monoxide detectors were tested and observed to be operational. LPA Vanegas observed a fire extinguisher to not be up to date and was expired.

CONTINUED ON LIC809C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: BALBOA ISLAND BOARD & CARE
FACILITY NUMBER: 300606338
VISIT DATE: 02/24/2025
NARRATIVE
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LPA Vanegas reviewed resident #1's resident file and observed that not all required documentation was in the file. LPA Vanegas observed that there was no file available for review of resident #2. A deficiency was cited on today's date. LPA Vanegas was not provided with a staff file for staff member that was on duty at the time of the visit, however staff member is cleared to work at the facility. A deficiency was cited on today's date.

LPA Vanegas reviewed all medications with AD, and per LPA Vanegas review all medications are being documented when administered, and are being administered per physicians orders. After observations made during today's visit deficiency's will be cited per tittle 22 chapter six of the California Code Of Regulations. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 02/24/2025 11:36 AM - It Cannot Be Edited


Created By: William Vanegas On 02/24/2025 at 11:09 AM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BALBOA ISLAND BOARD & CARE
FACILITY NUMBER: 300606338

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

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 in one out of three staff members no having a staff file with all required documentation; which poses a potential health risk to persons in care.
POC Due Date: 03/17/2025
Plan of Correction
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Administrator will ensure to get required staff records and create a folder for staff member. Administrator will send proof of correction via email to LPA Vanegas by P.O.C due date

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:Armando J Lucero
LICENSING EVALUATOR NAME:William Vanegas
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 02/24/2025 11:36 AM - It Cannot Be Edited


Created By: William Vanegas On 02/24/2025 at 11:09 AM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BALBOA ISLAND BOARD & CARE
FACILITY NUMBER: 300606338

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

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 in one out of three staff members not having an availiable staff file to review; which poses a potential health risk to persons in care.
POC Due Date: 03/17/2025
Plan of Correction
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Administrator will ensure to get required staff records and create a folder for staff member. Administrator will send proof of correction via email to LPA Vanegas by P.O.C due date
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

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 in one out of two residents not having an available resident record for review; which poses a potential health risk to persons in care.
POC Due Date: 03/17/2025
Plan of Correction
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Administrator will create a resident file for resident in care, and send proof of correction to LPA Vanegas via eamil by P.O.C due date.
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:Armando J Lucero
LICENSING EVALUATOR NAME:William Vanegas
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 02/24/2025 11:36 AM - It Cannot Be Edited


Created By: William Vanegas On 02/24/2025 at 11:09 AM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BALBOA ISLAND BOARD & CARE
FACILITY NUMBER: 300606338

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

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 there were no available disaster prepeardiness plan or infection control plan available for review; which poses/posed a potential health and safety risk to persons in care.
POC Due Date: 03/17/2025
Plan of Correction
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Administrator will aquire infection control plan and disaster preparidness plan. AD will have the plans filled out and send proof of correction via email to LPA Vanegas by P.O.C due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Armando J Lucero
LICENSING EVALUATOR NAME:William Vanegas
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2025


LIC809 (FAS) - (06/04)
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