Lake Balboa Boarding Care

Allegation investigated: Staff placed a resident on hospice without obtaining permission from resident's responsible party.

Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent unannounced visit to deliver findings for the allegation listed above. The LPA met with Anait Asatrian and explained the reason for the visit. On 01/13/2025, the CCLD Department received the allegation listed above. On 01/22/2025 Licensing Program Analyst (LPA) Sandra Urena conducted an initial unannounced visit to investigate the allegation listed above. The LPA met with the Administrator and explained the reason for the visit. LPA Urena interviewed the Administrator and requested records pertinent to the investigation. Cntinues on LIC 9099C... Substantiated Staff placed a resident on hospice without obtaining permission from resident's responsible party. The allegation of “Staff placed a resident on hospice without obtaining permission from resident's responsible party” alleges that Resident #1 (R1) was admitted to a Hospice company without their Power of Attorney’s (POA) consent. To investigate the allegation LPA Urena conducted interviews and record reviews pertinent to the allegation. On 01/22/2026, the LPA interviewed the facility Administrator and asked about the services being provided to R1 by the hospice agency staff; the Administrator could not explain the services the hospice agency provided to R1. Furthermore, the administrator stated that the services “Were possibly for supplies and residents' condition” but could not specify what condition. When asked, who (family/POA) signed for the hospice services, the Administrator replied, " When I admitted the resident, the family agreed to put the resident in hospice". The LPA requested the Hospice records for R1, and the Administrator stated, "They took everything". When the LPA asked, "Who took everything?" the Administrator stated, "I don't know, the family". The LPA reviewed R1’s file and observed that the hospice admission paperwork for hospice services was missing from R1’s facility records. The LPA subpoena R1’s records from the hospice agency and received the documents on 06/08/2026. The LPA observed the POA’s name and signature on the hospice documents. On 07/08/2026, the LPA interviewed the POA and provided them with the documents for review. The POA confirmed that the signature and the initials on the document did not match their own. LPA confirmed that at the time R1 was enrolled with the Hospice agency, R1 was under the care and supervision of the facility. The physician’s report did not provide information that would support the need for hospice services for R1. Based on the information obtained during interviews and record review, there is sufficient evidence to support the allegation of “Staff placed a resident on hospice without obtaining permission from resident's responsible party.” Therefore, the allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies were cited (refer to LIC 9099-D). Citations were issued. An exit interview was conducted. A copy of the report and, appeal rights were issued.the state’s words, verbatim · CDSS document, Aug 6, 2026 · control 29-AS-20260113110402

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(7) · Plan of correction due date: Aug 7, 2026

87468.2(a)(7) Additional Personal Rights... (a) ...shall have all of the following personal rights: (7) To fully participate in planning their care, ... and involve persons of their choice in this planning... This requirement is not met as evidenced by: Based on interviews and record review the licensee did not comply with the section cited above as R1 was enrolled with a hospice company with a falsified signature while under the care and supervision of the facility which posed a potential risk to persons in care.the state’s words, verbatim · CDSS document, Aug 6, 2026

Plan of correction: Administrator will submit a signed statement of understanding confirming that they understand the importance of residents participating in the planning of their care and confirming that the Administrator will review and retain at the facility all hospice records for residents at least five (5)years. Administrator agreed to submit the statement to CCLD no later than POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual inspection. The LPA was greeted by staff, and staff contacted the Administrator by phone. The LPA spoke on the phone with the Administrator Anait Asatrian and explained the reason for the visit, the Administrator stated it would take them about an hour to get to the facility. The Administrator arrived at the facility shortly thereafter. The LPA and the Administrator arrived at the facility. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and facility is in compliance with Title 22 Regulations. COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature of 76 degrees. Smoke detectors were tested and operational at the time of the visit. The carbon monoxide was not part of the smoke detector, and the facility did not have a carbon monoxide detector. The fire extinguisher was last serviced on 01/15/2024. The LPA observed the required postings throughout the common space. The facility serves residents with dementia, the auditory alarms on the exit doors were not functional at the time of visit. At approximately 10:48 the LPA observed a medication basket sitting on the dining room table which belonged to one of the residents and a bag of medication from the pharmacy also with bottles of medications accessible to residents in care. Continues on LIC 809C...page 2. Staff living area is located in the front of the home. A connecting door between the staff living area and the facility area was observed. The LPA observed it to be unlocked and accessible to residents in care KITCHEN: Knives are stored inaccessible in a kitchen drawer. Kitchen appliances were in operable condition. Kitchen cleaning supplies were observed under the kitchen sink in locked and inaccessible to residents in care. The facility has a sufficient supply of perishable and non-perishable food. The hot water temperature measured at….degrees Fahrenheit. BEDROOMS: Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are four designated residents’ rooms. Linen closet is located inside bedroom # 4. The closet was observed to be locked at the time of the visit. BATHROOMS: Two (2) bathrooms were observed to be clean and sanitary and in operating condition. First bathroom is located in the hallway; the hallway’s bathroom paper toilet holder was observed to be broken with only one half of the prongs still attached to the wall. Furthermore, the LPA observed cleaning supplies and grooming supplies next to the bathtub and accessible to residents in care, and requires a trash can with tight fitting lid. The second bathroom is a private bathroom which is located inside bedroom #4. The private bathroom needs to have safety grab bars installed. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature measured in the hallway restroom at 119.9 degrees Fahrenheit. LAUNDRY ROOM: A laundry area was observed with unlocked folding doors. A bottle of detergent was observed in an unlocked top cabinet above the washer and dryer and accessible to residents in care. OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate for client use and is single-latched. No bodies of water noted. A back side gate behind the storage area was observed to be unlocked and the area accessible to residents in care. The Administrator attempted to close the gate, however the gate’s padlock was not working and did not engage. Gate needs to be fixed to close completely and engage lock. Continues on LIC 809C... page 3. Pg 3. RECORDS: Records review began at 12:25 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, and consent forms. Record review revealed that four out of four files were missing some or all of the following: SNP(signatures). No LIC 601/ID, No LIC621- SPV- MA missing Physician contact information. One out of five residents’ file was missing. Per the Administrator the resident was admitted to facility without any personal or medical documentation. At the time of the visit the LPA attempted to communicate with the resident’s family contact, the call was unanswered, and LPA was unable to leave message. Resident’s DOB and last name is unknown. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. One (1) out of three (3) staff files was missing, some or all of the following required forms: LIC 501, 508, 9052, ED, FPCL- Staff works two days per week. MEDICATIONS: Medications review began at 02:05 p.m.; medications are centrally stored and locked in a cabinet in the common area; medications are labeled and were checked for expiration dates. Medications were not properly documented on the centrally stored medications and destruction record form (LIC622). Errors observed during the medication review, as one out of one medication audit indicated that the following medications were not administered as prescribed, where medications were not given daily: Methocarbamol (500 mg/30 count), Benazepril (40mg/30 count), Amlodipine. The LPA requested the following documents: - LIC500 Personnel Report-Was not available for review. - LIC9020 Client Roster-Available- but not completely filled-out. - Liability of Insurance. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. The Administrator was informed of the late license fees due for the facility. Exit interview conducted. A copy of the report and Appeal Rights was issued.the state’s words, verbatim · CDSS document, Sep 17, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual inspection. The LPA met with the Administrator Anait Asatrian and explained the reason for the visit. The LPA and the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature of 76 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was fully charged and was last serviced on 01/15/2024. The LPA observed some of the required postings throughout the common space. The CCL poster “If you see something, Say Something” poster was not available at the facility. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and were not functional at the time of visit. Staff living area is located in the front of the home. A connecting door between the staff living area and the facility area was observed. LPA observed it to be inaccessible to residents in care. KITCHEN: At 11:35 a.m. the LPA and administrator observed two kitchen knives on the kitchen counter and in an unlocked kitchen drawer to be accessible to residents in care. All other knives are stored inaccessible in a kitchen drawer. Kitchen appliances were in operable condition. Kitchen cleaning supplies were observed under the kitchen sink in an unlocked cabinet, and accessible to residents in care. The facility has a sufficient supply of perishable and non-perishable food. The hot water temperature measured at 112.8 degrees Fahrenheit. Continues on LIC 809 C... Pg. 2 BEDROOMS: Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are four designated client rooms. All beds were observed to have full bedrails, although bedrails were not observed to be in the upright position. In bedroom #2, was observed to have a small locker type cabinet with six (6) compartments. The compartments have locks. The Administrator stated that the small locker is used by staff to put away their belongings. Locker will be removed. BATHROOMS: Two bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces in one bathroom. The private bathroom need to have safety grab bars installed. The bathrooms were sufficiently stocked with soap and paper towels. Trash cans did not have a tight closing lid. The hot water temperature measured in the hallway restroom at 119.9 degrees Fahrenheit. LAUNDRY ROOM: A laundry area was observed with unlocked folding doors. A bottle of detergent was observed on the washer. An unlocked cabinet over the washer and dryer which has personal item supplies and scissors, was observed to be unlocked, accessible to residents in care. OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate for client use and is single-latched. No bodies of water noted. RECORDS: Records review began at 1:35 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. Three out of four residents’ files were missing some or all of the following required forms: LIC 601, LIC 613, LIC 621. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Three out of four residents’ files were missing some or all of the following required forms: 20-hour required annual training, Criminal Statements, CPR/First Aid, Personnel Record. Continues on LIC 809C... Pg. 3 MEDICATIONS: Medications review began at 3:45 p.m.; medications are centrally stored and locked in a cabinet in the common area; medications are labeled and checked for expiration dates. Medications were not properly documented on the centrally stored medications and destruction record form (LIC622). Errors observed during the medication review, as four out four residents’ LIC 622 forms ere filled out incorrectly, and at least one medication: Quetiapine 25mg/30 was found to have six(6) more pills than the correct amount. INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The LPA reviewed the following documents: - LIC500 Personnel Report - LIC9020 Client Roster The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties Exit interview conducted. A copy of the report and Appeal Rights was issued.the state’s words, verbatim · CDSS document, Sep 17, 2024