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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700527
Report Date: 08/20/2024
Date Signed: 08/20/2024 12:51:13 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/23/2024 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240723093829
FACILITY NAME:BALANCE ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
392700527
ADMINISTRATOR:BREMER, MERLENEFACILITY TYPE:
740
ADDRESS:1321 S FAIRMONT AVENUETELEPHONE:
(209) 334-3436
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:145CENSUS: 66DATE:
08/20/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH: Marlene Bremer, Jonathan Aguilar, and Stephen RatliftTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff handle resident(s) in care in a rough manner.
Resident is physically abusing other residents in care due to lack of staff supervision, causing injury.
Licensee does not ensure that residents are provided with a safe environment while in care.
Staff did not seek medical attention for resident as necessary.
Staff do not ensure that facility is clean.
Staff do not ensure that facility is sanitary.
Licensee does not ensure that residents are able to request assistance when needed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 08/20/2024 at 9:30 AM to deliver complaint findings, LPA met with Jonathan Aguilar and explained the purpose of the visit.

Throughout the course of the investigation, LPA Martinez conducted interviews, reviewed facility records, and inspected the facility. It was determined resident one (R1) was physically abused by staff 1 (S1). Per facility notes and SOC 341 Suspected Dependent Adult/Elder abuse report, staff 2 (S2) witnessed S1 restraining R1 to the ground with their body and hands. In addition, the facility did not prevent staff from rough handling R1. Staff 3 (S3) deliberately shoved a food cart into R1, which was observed by a facility visitor and staff. It was learned S3 was terminated and law enforcement was called. As a result, the facility did not create a safe environment for residents in care.

Continued...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
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 9
Control Number 27-AS-20240723093829
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 08/20/2024
NARRATIVE
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 An immediate $1,000.00 civil penalty shall be assessed on August 20, 2024; based on the fact the facility did not provide a safe environment and failed to protect R1 from physical abuse, punishment, and humiliation. This posed an immediate threat to the Health, Safety, and Personal Rights of R1.

Because you have been cited for repeating the same violation within 12 months (California Code of Regulations Section 87468.1(a)(2)), a civil penalty in the amount of $1,000.00 shall be assessed 08/20/2024. Please refer to LIC 421IM form for additional information.


Moreover, resident 2 (R2) has aggressive behaviors and has a history of resident-on-resident altercations. R2’s assessments indicate they have aggressive behaviors. R2’s July 24, 2023, Assisted Living Waiver Program assessment (ALWP) reports R2 becomes agitated, disruptive, and/or aggressive either physically or verbal 1-3 times per week. R2’s August 18, 2023, LIC 602 Physicians report indicates they have aggressive behaviors. R2’s Needs and Services Plans have discrepancies. Some of R2’s Needs and Service plans are missing responsible party signatures, missing facility staff signatures, and missing dates. The current Needs and Service plan is not dated and not signed. Furthermore, the Needs and Service plan does not address how staff will supervise R2 and prevent them from being aggressive towards residents in care.

The investigation reveled the facility did not implement an adequate care and supervision plan that would address R2's aggressive behaviors. Additionally, the facility did not create a safe environment for residents in care and did not prevent resident on resident altercations. It was learned R2 had the following behavior incidents:
  • On September 22, 2023, R2 was not at their baseline and sent to the Emergency Room (ER) for anger, agitation, and aggression.
  • On September 30, 2023, R2 shoved R1 to the ground. R1 sustained head injuries and was sent to the ER.
  • On July 20, 2024, R2 was in a physical altercation with R3. R4 was sent to ER, and diagnosed with a closed head injury and a injury on their right hip.
Continued...
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 27-AS-20240723093829
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 08/20/2024
NARRATIVE
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Moreover, R2's current Needs and Service Plan only indicates to have them separated from R1; however, R2 has show to be aggressive towards any resident residing at this facility. The facility has shown their inability to create a safe environment for all residents in care, which is an immediate health and safety concern. An immediate health and safety civil penalties shall be assessed on August 20, 2024 in the amount of $ 2,000.00, which is the total amount for the above mentioned two resident on resident incidents. The two immediate health and safety penalties are assessed at $1,000.00 each. The civil penalties are assessed at $1,000.00 each because you have been cited for repeating the same violation within 12 months (California Code of Regulations Section 87464(f)(1)).Please refer to LIC 421IM form for additional information.

The investigation also revealed on July 10, 2024, R3 reported they did not feel good. A Med-tech checked R3 temperature. However, the facility did not make an attempt to contact R3' physician. R3 was sent to Emergency Room (ER) on July 11, 2024 for lower abdomen pain. R3 was admitted into the hospital and discharged on July 24, 2024. Upon discharge, the facility did not conduct a reassessment. Additionally, the facility did not have a proper incontinent assessment plan put in place. On July 26, 2024, facility staff had concerns about R3's urinary output. A physician communication note was sent to R3 Physician on July 26, 2024. However, there was no follow up for no response, and R3 was not sent to the ER. On July 28, 2024, R3 was sent to the ER due severe back pain. It is noted R3 was in tears and unable to move and complained of shortness of breath (SOB). R3 did not return from the hospital, and R3's family members picked up R3's belongings. Based on the information gathered, the facility did not seek timely medical attention for R3 and did not complete proper assessments. Because you have been cited for repeating the same violation within 12 months (California Code of Regulations Section 87465(g)), a civil penalty in the amount of $1,000.00 shall be assessed 08/20/2024. Please refer to LIC 421IM form for additional information.

Furthermore, It was learned the facility does not have a signal system in the memory care unit. Also, the facility plan of operation does not include a plan on how residents will summon staff. The plan of operation does not indicate how staff will conduct resident monitor checks. As a result, signal deficiency can be found on the 9099 D page.

Continued...
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/23/2024 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240723093829

FACILITY NAME:BALANCE ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
392700527
ADMINISTRATOR:BREMER, MERLENEFACILITY TYPE:
740
ADDRESS:1321 S FAIRMONT AVENUETELEPHONE:
(209) 334-3436
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:145CENSUS: 66DATE:
08/20/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH: Jonathan AguilarTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident(s) developed UTI's while in care.
Resident had inappropriate interactions with other resident due to lack of staff supervision while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 08/16/2024 at 9:030 AM to deliver complaint findings, LPA met with Jonathan Aguilar and explained the purpose of the visit.

Throughout the course of the investigation, LPA conducted interviews, reviewed facility records, and inspected the facility. Based on facility records and medical records there was not sufficient evidence to show that residents developed Urinary Track Infection (UTI) due to lack of water intake and being left in a soiled brief. Additionally based on interviews there was not enough evidence to prove R2 touched R4 inappropriately. It was further learned R2 is a registered sex offender, however, the facility did not complete a proper assessment that included a plan that would address R2's sexual behaviors. Please see case management for deficiencies. Due to the above noted information, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 27-AS-20240723093829
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 08/20/2024
NARRATIVE
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LPA Martinez toured the Memory Care outdoor resident patio with Administrator, Jonathan Aguilar, on August 16, 2024. The walkways were not sanitary. The walkways were littered with with the following: string cheese wrappers, mustard packages, ketchup packages, wicker debris (from broken wicker chairs), and dirt and flower petals build up on walkways. The Administrator called a maintenance employee during the inspection to have the broken wicker chairs removed. Deficiency can be found on the 9099 D page.

Because you have been cited for repeating the same violation within 12 months (California Code of Regulations Section 87303(a)), a civil penalty in the amount of $1,000.00 shall be assessed 08/20/2024. Please refer to LIC 421IM form for additional information.

Due to multiple residents sustaining serious bodily injuries and death, the violations warrant civil penalty assessments. At this time, the civil penalty assessments are under review, and a civil penalty determinations are pending by the Department. Once civil penalty assessments have been determined, an LPA will return at a future date to assess the civil penalties. (The civil penalties are for: timely medical attention, resident on resident altercations, and staff handling resident in a rough manner).



As a result of this investigation, the Department finds these allegations to be Substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations.

An exit interview was conducted, and a copy of this report, appeals rights, and LIC 421IM was provided to the facility.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC9099 (FAS) - (06/04)
Page: 9 of 9
Control Number 27-AS-20240723093829
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/20/2024
Section Cited
CCR
87303(a)
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87303(a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidence by: based on facility inspection, the Licensee did not ensure Memory Care Patio was sanitary and clean. This posed an immediate health and
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Debris cleared on 08/20/2024. Debris was cleared during facility visit.
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safety risk to residents in care.
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Type A
08/30/2024
Section Cited
CCR
87465(g)
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87465(g) Incidental Medical and Dental CareThe licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis. This requirement was not met
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Facility staff agrees to: conduct 911 training with Med-techs by POC 08/30/24. Email training documents to LPM Liza King by 5:00 PM.
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as evidence by, Based on interviews and facility review, the Licensee did not ensure R3 was provided timely medical attention when R3 reported they were not feeling well. This posed an immediate health and safety risk to R3.
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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: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 27-AS-20240723093829
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/07/2024
Section Cited
CCR
87468.1(a)(2)
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87468.1(a)(2)Personal Rights of Residents in All Facilities:Residents in all residential care facilities for the elderly shall have all of the following personal rights:To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. this requirement was not met as evidence by:
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Conducted personal rights training on August 07, 2024. POC Cleared.
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Based on interviews and records review, the Licensee did not ensure residents were provided a safe facility environment and free from physical abuse...due to not addressing R2's aggressive behaviors. This posed an immediate health and safety risk to residents in care.
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Type A
08/07/2024
Section Cited
CCR
87413(a)(2)
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Personnel - Operations: 87413(a)(2)In each facility:Care and supervision of residents shall be provided without physical or verbal abuse, exploitation or prejudice. This requirement was not met as evidence by: based on interviews and file review, the Licensee did not ensure staff did not
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Conducted personal rights training on August 07, 2024. POC Cleared.
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physically abuse R1. This posed an immediate health and safety risk to R1
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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: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 27-AS-20240723093829
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/30/2024
Section Cited
CCR
87464(f)(1)
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87464(f)(1) Basic Services: Basic services shall at a minimum include:Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living...This requirement was not met as evidence by:
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Facility staff agrees to: conduct basic service training with caregivers by POC 08/30/24. Email training documents to LPM Liza King by 5:00 PM.
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Based on records review and interviews, the Licensee did not ensure staff were providing basic care services to meet the needs of residents and provide care and supervision that would result in the prevention of R2 and R1 altercations this posed an immediate health and safety risk to residents in care
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CCR
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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: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 27-AS-20240723093829
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/30/2024
Section Cited
CCR
87464(f)(1)
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87464(f)(1) Basic Services: Basic services shall at a minimum include:Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living...This requirement was not met as evidence by:
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Facility staff agrees to: conduct Basic Service training with caregivers by POC 08/30/24. Email training documents to LPM Liza King by 5:00 PM.
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Based on records review and interviews, the Licensee did not ensure staff were providing basic care services to meet the needs of residents and provide care and supervision that would result in the prevention of R2 and R3 altercations this posed an immediate health and safety risk to residents in care
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Type B
09/03/2024
Section Cited
CCR
87303(i)(1)
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87303(i)(1) Maintenance and Operation: Facilities shall have signal systems which shall meet the following criteria:All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system... This requirement
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Signal system installed on 08/13/2024. Working on installing phone application. Email Liza King signal system update by 09/03/24 by 5:00 PM
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was not met as evidence by: based on facility inspection and interviews the memory care unit does not have a call system. 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: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 9