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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700527
Report Date: 11/03/2020
Date Signed: 11/03/2020 10:07:33 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:BALANCE ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
392700527
ADMINISTRATOR:ORELLO, MELISSAFACILITY TYPE:
740
ADDRESS:1321 S FAIRMONT AVENUETELEPHONE:
(209) 334-3436
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:145CENSUS: DATE:
11/03/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Melissa Orello, AdministratorTIME COMPLETED:
10:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Stephenie Doub contacted the facility on this day via telephone to complete a Case Management - Deficiencies visit. The visit was conducted via telephone due to COVID-19 and pre-cautionary measures. LPA spoke with Administrator (AD) Melissa Orello and explained the reason for the visit.

LPA requested to review the file of Resident 1 (R1). LPA observed the Pre-Admission Appraisal for R1 which was not signed by facility representative or resident responsible party. LPA interviewed R1 who stated that facility staff did not do an in person assessment or interview of R1 prior to R1 moving into the facility. Per the admissions agreement a refund of the Preadmission fee would be provided if a pre-appraisal was not completed. Per information provided through interviews and documentation, the facility did not adhere to the admissions agreement and did not complete a proper appraisal of R1 prior to admittance to the facility.

The following deficiencies were cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with AD Orello via telephone. A copy of this report along with a confidential names list and appeal rights was provided via email. An electronic response from AD Orello confirms receipt of this report.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Stephenie DoubTELEPHONE: (916) 767-4231
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020
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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BALANCE ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 392700527
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/10/2020
Section Cited

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Pre-Admission Appraisal - General. Prior to admission, the prospective resident and his/her responsible person, if any, shall be interviewed by the licensee or the employee responsible for facility admissions.
This regulation was not met as evidence by:
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The licensee did not ensure that the prospective resident was interviewed prior to admission to the facility. Based on information provided through interviews, R1 was not interviewed prior to admission. This poses a potenial risk to residents in care.
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Type B
11/10/2020
Section Cited

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Admission Agreements.The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments.
This regulation was not met as evidence by:
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The licensee did not comply with applicable terms in the admissions agreement. Based on documentation and information provided through interviews, the licensee did not provide a refund of the preadmission fee when the preappraisal was not completed. This poses a potential risk to residents.
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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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Stephenie DoubTELEPHONE: (916) 767-4231
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2020
LIC809 (FAS) - (06/04)
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