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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004008
Report Date: 01/30/2025
Date Signed: 01/30/2025 10:49:03 AM

Document Has Been Signed on 01/30/2025 10:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:BALMANIA'S CARE HOMEFACILITY NUMBER:
347004008
ADMINISTRATOR/
DIRECTOR:		BALMANIA, ERNAFACILITY TYPE:
735
ADDRESS:8980 NEPONSET DRIVETELEPHONE:
(916) 627-1772
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 2DATE:
01/30/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Artemio GordulanTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Case Management visit on 1/30/25 at 9:50am and met with Artemio Gordulan, Caregiver and stated the purpose of the visit.

LPA observed that S1 and S2 both completed required training's and is fingerprint cleared. However, S2 is not associated to the facility on LIS nor Guardian. A copy of the rosters were provided to the caregiver during this visit.

Based on LPAs observations, records review from regional Center and Facility, and interview with Caregiver the preponderance of evidence standards has been met.

Per California Code of Regulations, Title 22 Division 6, Chapter 6, deficiencies are being cited during this visit. If any deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview held, Appeal Rights discussed, Copy of report given.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 01/30/2025 10:49 AM - It Cannot Be Edited


Created By: Victoria Brown On 01/30/2025 at 10:20 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BALMANIA'S CARE HOME
FACILITY NUMBER: 347004008

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/31/2025
Section Cited
CCR
80065(i)(2)

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Personnel Requirements
(i) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:

(1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations or

(2) Request a transfer of a criminal record clearance as specified in Section 80019(f) or
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Licensee shall submit a fingerprint transfer to associate staff 2 to the facility. Completion of the assocation shall be submitted by fax to the Department by POC due date. Civil penalty in the amount of $500.00 assessed.
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Based on fingerprint check in LIS and Guardian S2 is not associated to the facility
This poses an immediate health and safety risk for persons in care.
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Type A
01/31/2025
Section Cited
CCR80066(a)(6)

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Personnel Records
The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:Documentation of the educational background, training and/or experience specified in licensing regulations for the type of facility in which the employee works.
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Licensee shall submit proof of completion of training for both S1 and S2. POC cleared prior to todays visit. Proof submitted during todays visit.
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Based on records review, confirmation from Regional Center and Caregiver the training was not completed.
This poses an immediate health and safety risk for 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:Stephen Richardson
LICENSING EVALUATOR NAME:Victoria Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2025


LIC809 (FAS) - (06/04)
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