392700527-11-3-2020-27-AS-KHOS-BUZSNA-20201103130112

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700527
Report Date: 11/03/2020
Date Signed: 11/03/2020 10:34:30 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/09/2020 and conducted by Evaluator Stephenie Doub

COMPLAINT CONTROL NUMBER: 27-AS-20200409161339

FACILITY NAME:	BALANCE ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	392700527
ADMINISTRATOR:	ORELLO, MELISSA		FACILITY TYPE:	740
ADDRESS:	1321 S FAIRMONT AVENUE		TELEPHONE:	(209) 334-3436
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY:	145	CENSUS: 69	DATE:	11/03/2020
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Melissa Orello, Administrator		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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Facility did not list preadmission fees in the admission agreement.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Stephenie Doub contacted the facility on this day to conclued a complaint investigation via telephone due to COVID-19 and pre-cautionary measures. LPA spoke with Administrator (AD) Melissa Orello and discussed the purpose of the call and the elements of the allegations.

The initial 10-day visit was conducted on 4/13/2020. LPA requested copy a of the admissions agreement for Resident 1 (R1). LPA also interviewed Administrator and R1 regarding the above allegation.

It was alleged that the facility did not list preadmission fees in the admission agreement. LPA reviewed the admission agreement provided to R1. In the Admission Agreement, the preadmission fees were disclosed in the agreement. The Admission Agreement was signed by representative of R1. Based on documentation provided the allegation that the facility did not list preadmission fees in the admission agreement was deemed UNFOUNDED.
(Continued on page 2)

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Stephenie Doub	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 27-AS-20200409161339

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 11/03/2020

NARRATIVE

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(Continued from page 1)
This agency has investigated the allegation noted. We have found it to be unfounded meaning it was false, could not have happened and/or was without a reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted with AD Orello via telephone and a copy of this report along with confidential names list was provided to AD via email. An electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Stephenie Doub	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/09/2020 and conducted by Evaluator Stephenie Doub

COMPLAINT CONTROL NUMBER: 27-AS-20200409161339

FACILITY NAME:	BALANCE ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	392700527
ADMINISTRATOR:	ORELLO, MELISSA		FACILITY TYPE:	740
ADDRESS:	1321 S FAIRMONT AVENUE		TELEPHONE:	(209) 334-3436
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY:	145	CENSUS: 69	DATE:	11/03/2020
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Melissa Orello, Administrator		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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Facility roof in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Stephenie Doub contacted the facility on this day to conclude a complaint investigation via telephone due to COVID-19 and pre-cautionary measures. LPA spoke with Administrator (AD) Melissa Orello and discussed the purpose of the call and the elements of the allegations.

The initial 10-day visit was conducted on 4/13/2020. LPA interviewed Administrator, Licensee and Resident 1 (R1) regarding the above allegation. LPA also reviewed invoice for roof repairs.

It was alleged that the facility was in disrepair due to the roof leaking in the room of R1. All parties interviewed confirmed that the roof was leaking. Per AD Orello and Licensee Representative Stephen Ratcliff, when heavy rains came, they discovered the leak in the room of R1. A tarp was immediately placed to prevent water from entering the room. The facility offered to move R1 to a different room, but R1 refused. The roof was repaired immediately. (continued)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Stephenie Doub	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 27-AS-20200409161339

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 11/03/2020

NARRATIVE

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(continued from page 3)
Based on the information provided through interviews and documentation, the allegation that the facility roof was in disrepair was SUBSTANTIATED. There was a preponderance of evidence to prove that the allegation occurred as reported.

The following deficiency was cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with AD Orello via telephone and a copy of this report along with confidential names list and appeal rights was provided to AD via email. An electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Stephenie Doub	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 27-AS-20200409161339

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 06/09/2020 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This regulation was not met as evidence by:	1 2 3 4 5 6 7	Deficiency cleared at time of visit. The roof has been repaired. Facility provided copy of invoice for repairs to LPA.
	8 9 10 11 12 13 14	The licensee did not ensure that the facility was in good repair at all times. Based on information provided through interviews and documentation, the facility roof was leaking and needed repair. This poses a potential risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Stephenie Doub	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 5 of 5