The Cottages of Lake Balboa 1

Type of visit: Annual/Random

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct the required annual inspection. The LPA met with the Administrator Justin Levi and explained the reason for the visit. At the time of the visit, the facility had 0 residents. The facility has been vacant (no residents) for three consecutive years. During today’s visit the LPA was advised that the facility will have a Change of Ownership. The future licensee/administrator was at the facility during today’s visit and reported that they submitted an application to the Centralized Application Branch (CAB) approximately one month and a half ago and have gone through the fire inspection. The LPA and the Administrator/and Applicant toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and that the facility is in compliance with Title 22 Regulations. COMMON AREAS: At the time of the visit, the living room and dining room furniture was observed to be in good condition. Living room area needs to be cleared of storage items (frames, wall pictures, etc.)The facility maintained a comfortable temperature. The ceiling air exhaust in the living room area was observed to have dust and dirt. Smoke detectors and carbon monoxide detectors were recently tested by the fire inspector. One fire extinguisher was fully charged and was last serviced on 02/02/2026. The LPA observed the required licensing information (Emergency exiting floor plan, resident's personal rights, Ombudsman information, Theft and loss policy and Emergency telephone numbers) were posted on the facility's wall near the front entrance. There is a foyer area between bedrooms #1 and #2 and the first bathroom. This area needs to be cleared. During the visit the LPA observed chemicals, a chainsaw and other items that are accessible and pose an immediate danger to potential residents. The hallway areas are missing night lights for safe passage from bedrooms #1 and #2 to the bathroom, and hallway from bedrooms #3, #4, and #5. Four (4) nightlights need to be installed. Remove table and printer next to bathroom #1 door. KITCHEN: Knives and cleaning supplies are to be stored inaccessible to residents in care. The knives and sharp objects drawer is missing the padlock. At the time of the visit, knives were not available at the facility. The Administrator stated that most of the utensils were relocated to the other facilities in the property, since this facility does not have residents. Kitchen appliances were in operable condition. Hot water temperature measured at 133.2 degrees. Due to the facility not having residents in the past three (3) years, the 7-day supply of non-perishable food and water is not available. Two 25-year buckets of non-perishable food were observed on a top shelf in the laundry room. However, the Administrator could not bring them down to be inspected by the LPA. A new supply will be purchased in the near future. Kitchen cupboards and cabinets were observed to in need of deep cleaning. Under sink cabinet was observed with chemicals and unlocked. BEDROOMS: The floor plan is approved for six residents’ rooms and one staff room. There was a linen closet in the hallway with extra towels and linens. The residents’ bedrooms are in the process of being remodeled and have some furniture, however the rooms need to be cleared of clutter. All rooms are single occupancy. Bedrooms #2, #4, and #6 have direct exit to the exterior perimeter of the facility. All bedrooms need to have fully made beds (sheets, blanket, comforter, pillows), trash cans with lids, a chair, closets cleared of all items, nightstand with lamp and flashlights. Bedroom #6 sliding screen door is in disrepair, needs to be fixed. Floor area next to the sliding door is broken and needs repair. BATHROOMS: There are two (2) bathrooms in the facility. Bathroom #1 was relatively clean and sanitary and in operating condition with grab bars non-skid surfaces, needs to have the sink water faucet secured as it was observed to be wobbly during the water temperature test. Both bathrooms were sufficiently stocked with soap and paper towels. Both bathrooms are missing a trashcan with tight fitting lid. Bathroom #2 needs a non-skid mat, needs to have the threshold floor repaired as it shows signs of wear and is broken. Hot water temperature measured at 131.5 degrees Fahrenheit in both bathrooms. OUTDOOR AREA: The backyard has outdoor area equipped with furniture for client use. Shade is missing. A patio umbrella will be added to provide shade. No bodies of water noted. The washer and dryer are in a room adjacent to the staff room. Cleaning supplies and disinfectants are kept locked in the laundry area. The LPA observed room unlocked. The Administrator was reminded that the room must be locked at all times. The passage way cleared and approved by the fire department must be free of clutter, during the visit the LPA observed several items blocking the passageway; furthermore a car is partially blocking the gate cleared by fire department as a fire exit. RECORDS: No residents’ or staff records were reviewed at this time. MEDICATION: No medication was audited at this time. Technical Violations were issued as no residents are currently admitted at the facility. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Sep 1, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct the required annual inspection. The LPA met with the Administrator Justin Levi and explained the reason for the visit. At the time of the visit, the facility had 0 residents. No staff was present at the time of the visit. The Administrator stated that they are waiting to get clients through a referral agency. The LPA and the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and that the facility is in compliance with Title 22 Regulations. COMMON AREAS: At the time of the visit, the living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. Smoke detectors and carbon monoxide detectors were tested and operational at the time of the visit. One fire extinguisher was fully charged and was last serviced 01/27/2025. The LPA observed required postings throughout the common space. KITCHEN: Knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: The floor plan is approved for six residents’ rooms and one staff room. There was a linen closet in the hallway with extra towels and linens. The residents’ bedrooms are in the process of being remodeled and have no furniture. BATHROOMS: Bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. No bodies of water noted. The laundry area and staff room were located to the right of the entry way door. LPA observed room to be inaccessible to residents in care. The washer and dryer are in a room adjacent to the staff room. Cleaning supplies and disinfectants are kept locked in the laundry area. RECORDS: No residents’ or staff records were reviewed at this time. The Administrator will inform the LPA when new residents are admitted, and staff start working. Once the LPA is informed, the LPA will return to review records. MEDICATIONS: No medications were reviewed at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Aug 14, 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 Administrator Justin Levi and explained the reason for the visit. At the time of the visit, the facility does not have residents. The Administrator stated that on April 11, 2024, he informed LPA Brian Basili via email, that due to the low number of residents at Cottages of Lake Balboa 1, the administrator was going to speak to the families of the residents about transferring the residents to Cottages of Lake Balboa 3; the families agreed, and three residents were transferred. No residents have resided at the facility for about two months. No staff was present at the time of the visit. The Administrator stated that they have applied to be a vendor through the Assisted Living Waiver (ALW) program and the Regional Center (RC). Administrator is awaiting approval from the ALW and RC. The Administrator stated that they may use some of the bedrooms as offices, but will inform and will request approval from the Community Care Licensing Department, prior to the changes. 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. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. One fire extinguisher was fully charged and were last serviced 01/09/2024. The LPA observed required postings throughout the common space. KITCHEN: Knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Continues on LIC 809C… BEDROOMS: The floor plan is approved for six residents’ rooms and one staff room. There was a linen closet in the hallway with extra towels and linens. The resident bedrooms were properly furnished with a bed, nightstand, and sufficient lighting for each resident. BATHROOMS: Bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. No bodies of water noted. The laundry area and staff room were located to the right of the entry way door. LPA observed room to be inaccessible to residents in care. The washer and dryer are located in a room adjacent to the staff room. Cleaning supplies and disinfectants are kept in locked in the laundry area. RECORDS: No residents’ or staff records were reviewed at this time. The Administrator will inform the LPA when new residents are admitted, and staff start working. Once the LPA is informed, the LPA will return to review records. MEDICATIONS: No medications were review at this time. 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. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Aug 22, 2024

Allegation investigated: Staff locked resident in a facility bedroom Resident's grooming needs were not met by facility staff Resident in care was locked out of the facility

Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver final findings of allegations listed above. During today’s visit, LPA met with Angie De Leon and explained the reason for the visit. On 07/03/2023, from 11:30 a.m. – 3:30 p.m., LPA initiated an unannounced complaint investigation for the allegations listed above. During the visit, LPA toured the physical plant, interviewed staff, resident and reviewed and obtained pertinent documents relevant to the investigation. On 10/30/2023, from 10:30 a.m. – 3:00 p.m., LPA conducted a subsequent complaint visit. During the visit, LPA toured physical plant, interviewed staff, families / responsible parties of residents in care and reviewed and obtained copies of additional documentation relevant to the investigation. It was reported that Staff locked resident in a facility bedroom, as it was alleged that Resident #1 (R1) was observed locked in their bedroom. Unsubstantiated Continued from 9099 Interviews conducted with five (5) residents, five (5) staff and four (4) families of residents in care revealed , that no one has observed any resident locked in their bedroom. During physical plant on the initial complaint visit, LPA observed that each bedroom door swung open towards the inside of the bedroom and each door did not have a lock. LPA’s interview with four (4) family member / responsible parties of residents in care revealed that each did not express any potential or immediate concerns for any resident to be locked in a bedroom. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff locked resident in a facility bedroom” is deemed Unsubstantiated at this time. It was reported that Resident’s grooming needs were not met by facility staff, as it was alleged that Resident #2 (R2)’s fingernails were observed to be long and dirty on multiple occasions. In addition, R2’s hair appeared to not have been brushed multiple times. LPA’s records review revealed that staff logged the following items daily; Residents food intake, toileting / bowel movements, and shower assistances. LPA did not observe anything in the records that indicated that any residents grooming needs were not met. Interviews conducted with five (5) staff revealed that each staff member have always observed R2 to appear to be bathed and groomed. Each staff also stated they have never observed R2’s finger nails to be long and dirty. In addition, the staff interviewed further revealed that a podiatrist visits the facility approx. every ninety day or upon request to service each resident. LPA's interview with Podiatrist revealed they have never observed any resident with long and dirty fingernails. LPA’s interview with four (4) family member / responsible parties of residents in care along revealed that each did not express any potential or immediate concerns for residents’ grooming needs not being met by facility staff. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Resident’s grooming needs were not met by facility staff” is deemed Unsubstantiated at this time. It was reported that resident in care was locked out of the facility as it was alleged that on one occasion R1 was locked out at the front door of the facility. Time and day of alleged incident were not provided to LPA. Interviews conducted with five (5) staff and five (5)residents revealed that each person interviewed have never observed any resident locked out of the facility. Continued from 9099-C LPA’s interview with four (4) family member / responsible parties of residents in care revealed that each did not express any potential or immediate concerns for any residents being locked out of facility. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “resident in care was locked out of the facility” is deemed Unsubstantiated at this time. Exit interview conducted and copy of report issued.the state’s words, verbatim · CDSS document, Mar 18, 2024 · control 29-AS-20230626091233

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced Case Management - Incident Visit to follow up on a SOC 341 01-17-2024. LPA met with Angie De Leon and explained the reason for the visit. On 01/17/2024, the department reviewed a SOC 341, for Resident #1 (R1) along with a copy which indicated Staff #1(S1), allegedly took their shirt off in R1's room along with almost taking their pants off. S1 has since been placed on administrative leave pending a full investigation. At approx 2:30 p.m., LPA conducted physical plant, interviewed staff, residents as well as reviewed and obtained pertinent documents relevant to the investigation. LPA did not observe any immediate or potential health and safety concerns at this time. The LPA has determined further investigation is needed and will return at a later date to complete the investigation if warranted. Exit interview conducted and copy of report issued.the state’s words, verbatim · CDSS document, Jan 22, 2024