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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608363
Report Date: 08/06/2026
Date Signed: 08/06/2026 02:27:40 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/13/2026 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20260113110402
FACILITY NAME:LAKE BALBOA BOARDING CAREFACILITY NUMBER:
197608363
ADMINISTRATOR:ANAIT ASATRIANFACILITY TYPE:
740
ADDRESS:15830 MARLIN PLACETELEPHONE:
(818) 793-9814
CITY:LAKE BALBOASTATE: CAZIP CODE:
91406
CAPACITY:6CENSUS: 6DATE:
08/06/2026
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Anait AsatrianTIME COMPLETED:
02:24 PM
ALLEGATION(S):
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Staff placed a resident on hospice without obtaining permission from resident's responsible party.
INVESTIGATION FINDINGS:
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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
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 29-AS-20260113110402
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: LAKE BALBOA BOARDING CARE
FACILITY NUMBER: 197608363
VISIT DATE: 08/06/2026
NARRATIVE
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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.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 29-AS-20260113110402
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: LAKE BALBOA BOARDING CARE
FACILITY NUMBER: 197608363
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/07/2026
Section Cited
CCR
87468.2(a)(7)
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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:
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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.

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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.
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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.
SUPERVISOR'S NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2026
LIC9099 (FAS) - (06/04)
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