The Cottages of Lake Balboa 2

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sandra Urena arrived unannounced at the facility to conduct the required annual inspection. The LPA was greeted by staff and informed them of the reason for the visit. The staff informed the Administrator of the visit. The LPA explained the reason for the visit to the staff Daniel Lim. The LPA and the staff 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. The fire extinguisher was fully charged and was last purchased on 02/05/2026. The exhaust vent above the dining room table was observed to have dust accumulated on the vents and was observed to have some type of foreign object stuck on the vent. One smoke alarm device near one of the exit doors was missing, with wires exposed and a second smoke detector was not functioning . The Community Care Licensing Poster was not posted at the time of the inspection. The LPA observed most of the required postings throughout the common space. Motion sensor night lights were missing in the hallways leading to the bathrooms. 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. The hot water temperature measured 119.7 degrees Fahrenheit. The refrigerator and the freezer do not have a thermometer to ensure that the refrigerator and freezer are kept at the required temperatures (40 degree -0 degrees). Continues on LIC 809C..page 2 The LPA observed at least three (3) Ziplock baggies of food with dates written on them; however, the baggies were not labeled with the content of the food inside the baggies. Furthermore, a ziplock baggie with a powder was observed in the pantry cabinet and did not have a label to identify the contents. Kitchen drawers, cupboards, and dishwasher were observed to be dirty and unsanitary. BEDROOMS: There are six (6) residents’ private bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The LPA made the following observations. Bedrooms 4, 3, and 1 are currently vacant. The sliding closet door for Bedroom 3 needs to be fixed as it is currently coming off the rails when open. Bedroom 4 closet must be emptied as it currently has items that belonged to a previous resident. Closet in bedroom #1 was observed to have cobwebs and dusty. BATHROOMS: The facility has three full bathrooms. Two bathrooms are considered common bathrooms for residents’ use, and one bathroom is a private bathroom #3 located inside bedroom 1. The common bathroom #1, has a broken toilet paper holder, and is missing a nonskid mat; and toilet grab bars. The common bathroom #2 has portable toilet grab bars that show signs of wear with some areas of the metal areas rusted, which pose a danger to residents in care and is missing a nonskid mat. Additionally, a trashcan without a lid was observed in bathroom #2 and the private bathroom #3.The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature measured 119.7degrees Fahrenheit. OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. No bodies of water noted. Cleaning supplies and disinfectants are kept in locked cabinets. RECORDS: Records review began at 12:54 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. MEDICATIONS: Medications review began at 2:35 p.m.; medications are centrally stored and locked in a cabinet in the kitchen area. Medications are labeled and checked for expiration dates. The medications are documented on the centrally stored medications and destruction record, however, the medications for three (3) out of three (3) residents do not list the START DATE of the medication, consequently, the LPA was not able to conduct a medication audit. For one (1) out of three (3) residents, it was observed that the LIC 622 had only one medication listed “Ondansetron”, however, when the LPA inspected the resident’s medication basket, the LPA observed that the following medications were not listed: Dorzolamide, and Latanoprost, Tylenol and Docusate. Furthermore, for (1) out of three (3) residents, it was observed that the daily medications were sorted in a weekly pill box, but the medication bottles were not in the resident’s medication basket. When the LPA brought this to the staff’s attention, the staff brought the medication bottles from different location outside the facility. The LPA reviewed the following documents: - LIC500 Personnel Report - LIC9020 Client Roster - Certificate of Liability of Insurance Emergency Drill Logs- The facility recently admitted their first resident in 08/2026. The staff were advised to conduct the first drill as soon as possible. The LPA spoke with the Administrator Justin Levi, on the phone and the Administrator was unavailable to sign the report instructed staff Aura Melgar to sign the report on their behalf. Citations were issued. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Sep 24, 2026

The state marks this report as 14 pages; the online copy we transcribed has 9. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual visit. The LPA met with Administrator Justin Levi and explained the reason for the visit. The facility is currently vacant and has 0 residents, The Administrator stated that they are waiting to get clients from referral agencies. No staff was present at the time of 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. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. One fire extinguisher was fully charged. 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 residents’ bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. BATHROOMS: Bathrooms were 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 outdoor area has a shaded area equipped with furniture for client use. No bodies of water noted. LPA observed room to be inaccessible to residents in care. The washer and dryer are oeprational. 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 visit. The LPA met with Administrator Justin Levi and explained the reason for the visit. The facility is currently vacant as they are awaiting to become vendored with Los Angeles Regional Center. LPA did not observe any residents at the time of the visit. No staff was present at the time of 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. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. One fire extinguisher was fully charged. 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 resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. BATHROOMS: Bathrooms were 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, Sep 13, 2024