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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700527
Report Date: 09/12/2024
Date Signed: 09/12/2024 04:40:52 PM


Document Has Been Signed on 09/12/2024 04:40 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:BALANCE ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
392700527
ADMINISTRATOR:AGUILAR, JONATHANFACILITY TYPE:
740
ADDRESS:1321 S FAIRMONT AVENUETELEPHONE:
(209) 334-3436
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:145CENSUS: 62DATE:
09/12/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Jonathan AguilarTIME COMPLETED:
05:00 PM
NARRATIVE
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On 9-12-24 at 2:30pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding staff training and resident assessment. LPA met with Administrator and explained the purpose of the visit. LPA reviewed appraisal form and physician's report for resident1 (R1) during today's case management. LPA also conducted brief interview with Administrator and staff1 (S1).

Based on interviews and record reviews, it was determined that R1 is a previous resident of facility who engaged in excessive drinking of alcohol resulting in frequent intoxication. It was further revealed that R1 suffered bleeding after biting his tongue after an experience of intoxication which required a caregiver to intervene and perform infection control cleaning techniques. It was additionally determined that this caregiver did not receive infection control training per regulatory requirements.

As a result of today's case management, citations are issued under Title 22, Division 6. A civil penalty in the amount of $250 is issued due to a repeat violation of Section 87463(a) within a 12-month period An exit interview was conducted with Administrator and a copy of this report was provided to Administrator. Appeal rights provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024
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 09/12/2024 04:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: BALANCE ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 392700527

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/20/2024
Section Cited
CCR
87463(a)

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Reappraisals. (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate...This requirement was not met as evidenced by:
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Licensee to submit a plan outlining procedures on identifying new onsets of resident needs and reflecting in the needs and service plans. Plan to be submitted to LPA by POC due date.
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Based on interview and record review, R1 demonstrated excessive drinking and intoxincation and not addressed on a reappraisal. This posed a potential health and safety risk to residents in care.
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Type B
10/14/2024
Section Cited
CCR87470(c)(1)(C)(1)

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Infection Control Requirements. (c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1)The Infection Control Plan shall include all of the following:(C) An Infection Control Training Plan. 1.Initial training requirements for new facility staff shall be addressed in the plan, with training to be provided by the Infection Control Lead before staff works independently with residents. This requiement was not met as evidenced by:
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Licensee to ensure all staff receive infection control training as part of initial and on-going training requirements. Proof of completed training to be submitted to LPA by POC due date.
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Based on interview and record review, S2 did not receive infection control training per requlatory requirements prior to infection control cleaning techniques performed. This posed a potential health and safety risk to residents 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: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024
LIC809 (FAS) - (06/04)
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