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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602434
Report Date: 10/01/2026
Date Signed: 10/01/2026 03:09:17 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/01/2026 03:09 PM - It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:GARDENS AT PARK BALBOA, THEFACILITY NUMBER:
197602434
ADMINISTRATOR/
DIRECTOR:		DION D GALLARZAFACILITY TYPE:
740
ADDRESS:7046 KESTER AVENUETELEPHONE:
(818) 787-0462
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY: 120CENSUS: 105DATE:
10/01/2026
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:16 AM
MET WITH:Dion GallarzaTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a continuation of the required annual visit at 10:16 AM. LPA met with facility Executive Director (ED) Dion Gallarza. Entrance interview was conducted and the reason for the visit was explained.

RECORD REVIEW: Record review began at 10:29 AM. Staff records were reviewed for documents including, but not limited to: TB test, health report, first aid training, finger print clearance, and required annual trainings. Ten (10) staff files were reviewed. All staff files contained all required documentation and trainings. No deficiencies were observed during record review.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. The facility’s emergency disaster plan is up to date and is adequate. Disaster drills are conducted monthly and the facility's last emergency disaster drill was conducted on 09/08/2026. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Executive Director.

MEDICATION REVIEW: Medication review began at 12:16 PM. Medications are stored centrally and securely in the medication room. LPA observed medications for ten (10) residents. LPA observed a total of sixteen (16) medications across four (4) residents to have incorrect quantities logged on their respective centrally stored medication and destruction record sheets (CSMDRs).

Continued on LIC 809C.

Kasandra Lopez
Trevor Byrne
DATE: 10/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GARDENS AT PARK BALBOA, THE
FACILITY NUMBER: 197602434
VISIT DATE: 10/01/2026
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INTERVIEWS: LPAs interviewed five (5) residents and five (5) staff members. All residents interviewed stated that the staff treat them well and are attentive to their needs. No residents interviewed had concerns with the facility. All staff members interviewed were knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse.

During today’s visit LPAs obtained a copy of the facility’s resident roster, LIC 500, and current liability insurance.

Pursuant to Title 22 of the CA Code of Regulations and/or the Health and Safety Code, the following deficiency was cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/01/2026 03:09 PM - It Cannot Be Edited


Created By: Trevor Byrne On 10/01/2026 at 02:55 PM
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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GARDENS AT PARK BALBOA, THE
FACILITY NUMBER: 197602434

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/15/2026
Section Cited
CCR
87465(h)(6)(C)

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87465 Incidental Medical and Dental Care
(h) The following... shall apply ...
(6) ... a record ... includes:
(C) The drug name, strength and quantity.
This requirement is not met as evidenced by:
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Executive Director agreed to conduct training with all staff responsible for completing CSMDRs on the importance of properly logging medications and proper procedures when logging medications. Executive Director agreed to submit proof of the completed training to CCLD no later than POC due date.
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Based on record review the licensee did not comply with the section cited above as sixteen (16) medications across four (4) residents to have incorrect quantities logged on their respective CSMDRs which poses a potential health risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2026


LIC809 (FAS) - (06/04)
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