392700527-2-17-2022-27-AS-KHOS-CBVJV2-20220222062226

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700527
Report Date: 02/17/2022
Date Signed: 02/17/2022 03:20:07 PM

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
12/23/2021 and conducted by Evaluator Treana White

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20211223165419

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: 62	DATE:	02/17/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Daisy Aguilar, Executive Director		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Staff not protecting resident from another resident entering the room.

INVESTIGATION FINDINGS:

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On 02/17/2022, Licensing Program Analyst (LPA) T. White conducted an unannounced complaint investigation regarding the above allegations. LPA White discussed the purpose of the visit and the elements of the allegations with Executive Director, Daisy Aguilar.

During the course of investigation, LPA M. Bilger collected the following documents, including resident roster and staffing roster, physician reports, needs and service plans, and appraisal forms for 3 Residents. A copy of facility's medication policy and procedure. LPA Bilger interviewed 2 staff members and reviewed medication assessment record (MAR) during visit. On 02/17/2022, LPA T. White interviewed 3 staff members, 3 residents and reviewed incidents reports.

REPORT CONTINUES on 9099C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022

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-20211223165419

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: 02/17/2022

NARRATIVE

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Staff not protecting resident from another resident entering the room.

Based on incident dated 12/24/2021, Staff #4 (S4) was walking around to start second round of change at 2 AM and observed R1 lying in bed with R3. S4 observed, R1 and R3 were sleeping back to back in the same bed. S4 stated she did not see anything sexual going on. Based on 3 staff interviews, this incident did occur during the night shift. LPA was unable to get in contact with night shift staff. Based on documentation, staff was unable to protect resident from entering R3's room.

Based on LPA's observation and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.

Exit interview conducted with Executive Director. A copy of report and appeal rights given.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022

LIC9099 (FAS) - (06/04)

Page: 4 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
12/23/2021 and conducted by Evaluator Treana White

COMPLAINT CONTROL NUMBER: 27-AS-20211223165419

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: 62	DATE:	02/17/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Daisy Aguilar, Executive Director		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Residents clothes were removed by another resident.
Resident not administered medication as prescribed.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 27-AS-20211223165419

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: 02/17/2022

NARRATIVE

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Residents clothes were removed by another resident.

On 02/17/2022, LPA T. White interviewed 3 residents and 3 staff members. Based on resident interviews, LPA was unable to obtain additional information from 3 of 3 residents, due to their dementia diagnosis. Based on staff interviews, 3 of 3 staff members stated there was no incident where a resident removed clothing from another resident. However, based on incident report submitted to CCLD, Resident #1 (R1) was found sleeping with only boxers on in Resident #3 (R3) room.

Resident not administered medication as prescribed.

On 12/28/2021, LPA Michael Bilger reviewed December 2021 MARS for memory care unit. Based on this record review, it was revealed that Med Techs have completed all the medication signing to indicate all residents have received medications. Review shows that there were no residents who refused or otherwise did not receive their medication based on Med Tech documentation. All current memory care resident MARS were reviewed.

On 02/17/2022, LPA T. White interviewed 3 staff members. Based on interviews, 3 of 3 staff stated residents prescribed medications are administered correctly. However, LPA is unable to prove or disprove if allegation occurred.

Based on interviews, observations and record review, it is determined that facility is currently meeting the regulatory food supply. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with Executive Director and a copy of report given.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 27-AS-20211223165419

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: 02/17/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/25/2022 Section Cited CCR 87705(c)(4)	1 2 3 4 5 6 7	Care of Persons with Dementia:(c)Licensees who accept and retain residents with dementia shall be responsible for ensuring...(4)...direct care staff to support each resident’s physical, social, emotional, safety... needs. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Executive Director agreed to conduct an in-service training with all staff and submit proof to CCL by POC date.
	8 9 10 11 12 13 14	Based on documentation, Facility did not comply with the section cited above in 87705(c)(4). Documentation stated S4 found R1 in R3's bed sleeping, which poses as a potential health and safety risks 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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 5