157202507-9-8-2022-24-AS-LSAR-CJ3SVK-20220908141251

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 157202507
Report Date: 09/08/2022
Date Signed: 09/08/2022 02:13:08 PM

Document Has Been Signed on 09/08/2022 02:13 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	BALANCE RESIDENTIAL CARE CORPORATION		FACILITY NUMBER:	157202507
ADMINISTRATOR:	BICERA, VICTORIA		FACILITY TYPE:	740
ADDRESS:	9802 VERTRICE AVE.		TELEPHONE:	(661) 665-0535
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93311
CAPACITY:	6	CENSUS: 4	DATE:	09/08/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Vicki Bicera, Licensee via telephone Staff Linda Natividad		TIME COMPLETED:	02:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 09/08/2022, Licensing Program Analyst (LPA) arrived unannounced to conduct an annual inspection. LPA was greeted by caregiver, introduced self and stated the purpose of the visit. LPA spoke to Licensee on the phone who was unable to attend the visit in person. Licensee has given permission for caregiver to sign for report based on the LIC 308 on file with the facility. There are four residents present during today's inspection, 3 of which are receiving Hospice services. LPA conducted a tour of the facility with caregiver. Facility is a 5 bedroom / 2 bathroom home. Facility staff were observed wearing facial coverings. There were no obstructions blocking walkways or fire clearance issues during this inspection. LPA observed a visitor log/temperature log at the entry. Hand sanitizer was available for visitors. LPA observed signs promoting hand-washing, social distancing, and cough/sneeze etiquette throughout the facility. LPA observed hand sanitizer in resident rooms. Resident bathroom observed to be stocked with paper towels and liquid soap. Hand-washing signs observed in the resident bathroom and kitchen. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. LPA checked medications. LPA observed a 30 day supply of PPE and cleaning supplies. No deficiencies issued during this inspection. (continued on LIC 809-C)

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa Salazar	TELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: BALANCE RESIDENTIAL CARE CORPORATION	FACILITY NUMBER: 157202507
	VISIT DATE: 09/08/2022

NARRATIVE

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(Continued from 809)

LPA is requesting the following documents be submitted to the Fresno CCL office by 09/23/2022: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Emergency and Disaster Plan (LIC610ES) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020)

An exit interview was conducted. A copy of this report was discussed and provided to caregiver, Linda Natividad, whose signature on this form confirms receiving this document.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa Salazar	TELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

LIC809 (FAS) - (06/04)

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