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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006422
Report Date: 07/18/2024
Date Signed: 07/18/2024 10:39:24 AM

Document Has Been Signed on 07/18/2024 10:39 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 SENIOR CAREFACILITY NUMBER:
306006422
ADMINISTRATOR/
DIRECTOR:		ATTRAH, AHMED & JERRAR, MOFACILITY TYPE:
740
ADDRESS:1669 N. FIRESIDE STREETTELEPHONE:
(949) 994-2900
CITY:ORANGESTATE: CAZIP CODE:
92867
CAPACITY: 6CENSUS: 3DATE:
07/18/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Mo Jerrar, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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
On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made a scheduled visit to the facility for the purpose of conducting a pre-licensing inspection. LPA was greeted and granted entry by Mo Jerrar, administrator.

An initial application for a license to operate as a Residential Care Facility for the Elderly was received by the Department on September 19, 2023 for a capacity of five non-ambulatory and one bedridden residents. This is a change of ownership with three residents already in care and a potential upcoming admission.

LPA accompanied by administrator toured the physical plant. The facility is a one-level home with a frontyard, backyard and attached garage. There are six private bedrooms and one shared bathroom and one guest bathroom. Each of the bedrooms include all necessary components of furnishing including a light, chair, storage space for personal items and a full-size bed as well as a supply of linen and bedsheets. Water temperature was measured to be within acceptable range. Common living spaces are present and a device connected to the internet is present for the use of the residents in care. Facility is clean, sanitary and free of odors in all areas inspected. Required posted documents are observed to be present.

Kitchen equipment is present and operating as required. Sharp items and cleaning supplies are confirmed to be secured. A sufficient supply of perishable and non-perishable food is present as required by Title 22 Regulations. The centrally stored medication storage is located in a secure cabinet and a separate cupboard in the bedroom's hallway. The garage is also used for additional storage of food along with emergency and back-up supplies. Staff and client records were reviewed and confirmed to include all necessary components, with the exception of one missing medical assessment for one of the three residents which has been removed from the premises and will be provided to LPA at a later time.
CONTINUED ON FORM LIC809-D
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2024
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 3
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 SENIOR CARE
FACILITY NUMBER: 306006422
VISIT DATE: 07/18/2024
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
CONTINUED FROM FORM LIC809
None of the residents currently admitted are receiving hospice care.

The fire clearance has been obtained and provided to the Department before the pre-licensing visit. Combined smoke and carbon monoxide detectors are observed throughout the facility and confirmed to be functional. One fire extinguisher present on the premises is observed to have current maintenance tags. First aid kit verified to be complete.

LPA and licensee toured the outside of the facility and observed it to be free of obstructions. One shaded area is present in the back of the house and is equipped with outdoor furniture for the enjoyment of residents and visitors. The perimeter gate present one one side of the house is self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises.

Component III was waived as the prospective licensee has already been acting as the current facility administrator and operates other licensed locations as well. This report was reviewed with facility representative and a copy of this report was emailed to the prospective licensee before the conclusion of the visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3