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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608363
Report Date: 09/29/2026
Date Signed: 09/29/2026 04:10:38 PM

Document Has Been Signed on 09/29/2026 04:10 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:LAKE BALBOA BOARDING CAREFACILITY NUMBER:
197608363
ADMINISTRATOR/
DIRECTOR:		ANAIT ASATRIANFACILITY TYPE:
740
ADDRESS:15830 MARLIN PLACETELEPHONE:
(818) 793-9814
CITY:LAKE BALBOASTATE: CAZIP CODE:
91406
CAPACITY: 6CENSUS: 6DATE:
09/29/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:49 AM
MET WITH:Anait AsatrianTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual inspection. The LPA spoke 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. The smoke detectors by the main entrance and inside the bedrooms were tested and operational at the time of the visit. However, the smoke and carbon monoxide detectors by the kitchen and hallway area were nonfunctional. The Administrator stated they will replace them right away. The fire extinguisher was last serviced on 09/19/2025. 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. 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.

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 seven-day supply was observed to be in a closet located inside bedroom #4. The LPA stated to the Administrator that the supply has to be relocated to another area. The Administrator stated that they will move the supplies to the outdoor garage.

Continues on LIC 809C...

Kasandra Lopez
Sandra Urena
DATE: 09/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2026
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: LAKE BALBOA BOARDING CARE
FACILITY NUMBER: 197608363
VISIT DATE: 09/29/2026
NARRATIVE
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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. BATHROOMS: Two (2) bathrooms were observed to be clean and sanitary and in operating condition. First bathroom is located in the hallway. 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 locked folding doors. Detergents were observed in a locked top cabinet above the washer and dryer and inaccessible 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 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 two (2) out of six (6) files were missing the following: Updated Annual Medical Assessments. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, First Aid/CPR training. One (1) out of three (3) staff files was missing current valid CPR and First Aid Certificate. Two (2) out of three (3) staff files were missing the 20 hours of annual training. 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 properly documented on the centrally stored medications and destruction record form (LIC622). No errors observed during the medication review.

The LPA requested the following documents:


- LIC500 Personnel Report
- LIC9020 Client Roster
- Liability of Insurance.
- Emergency Drills were not available.

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.

Exit interview conducted. A copy of the report and Appeal Rights was issued.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Sandra Urena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/29/2026 04:10 PM - It Cannot Be Edited


Created By: Sandra Urena On 09/29/2026 at 03:42 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: LAKE BALBOA BOARDING CARE
FACILITY NUMBER: 197608363

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review)], the licensee did not comply with the section cited above in [count] out of 2 out of 2 staff, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2026
Plan of Correction
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Licensee will ensure staff recive the 20 hours of training by POC date. Licensee will email proof of the training dates/times, topic, presenter, along with staf's along with proof staff name's and signatures.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review)], the licensee did not comply with the section cited above in no proof of emergency drills have been conducted for the past year, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2026
Plan of Correction
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Licensee will esure that a fire drill will be conducted by Friday October 02, 2026, and will email LPA proof with staff signatures dates and time,
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:
Sandra Urena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2026


LIC809 (FAS) - (06/04)
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