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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700527
Report Date: 09/26/2024
Date Signed: 09/26/2024 03:53:26 PM


Document Has Been Signed on 09/26/2024 03:53 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:
09/26/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jonathan AguilarTIME COMPLETED:
04:15 PM
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On 9/26/24 at 1:30pm, Licensing Program Analyst {LPA} Michael Bilger arrived unannounced to deliver findings on a previous case management investigation regarding care and supervision. LPA met with Administrator Jonathan Aguilar and explained the purpose of the visit. During this investigation, the Department conducted interviews with seven staff members, two residents, and three additional witnesses. The Department also reviewed file documentation including death certificate, medical records, care notes, service plan, admission agreement, physician’s report, appraisals, medication log sheets, and incident reports all pertaining to resident1 (R1).

On 01/30/2024 R1 had an unwitnessed fall in the hallway of the facility outside his room. R1 was transported to the hospital and diagnosed with a femoral fracture. R1 reported to facility staff and his family that he was walking to get exercise and fell. Per medical records, R1 reported that he had recently began walking again with his prosthetics and his walker and had tripped and fallen.



R1’s assessments and Individual Service Plan (ISP) detail that R1 had decreased gait and mobility with falls, but that R1’s goals included working on walking and being more independent and would work with Physical Therapy to become ambulatory on his prosthetics. Per R1’s ISP, facility staff would assist R1 with transfers, mobility, prosthetics and encourage the use of assistive devices until R1 was ambulatory with his prosthetics.

Based on care notes reviewed, R1 had one unwitnessed fall on 12/14/2023 while doing exercises and one witnessed incident on 01/02/2024 of his “leg giving out,” during an assisted transfer from his bed to
his wheelchair. Neither incident resulted in injury. Based on interviews conducted, R1 did not have a significant history of repeat falls. Interviews further revealed that when R1 first arrived at the facility, R1 stayed mostly in his wheelchair, but was very motivated to do exercises to build strength in walking with his prosthetics. {Cont. on 809C}
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024
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


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
VISIT DATE: 09/26/2024
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As R1 gained strength, R1 would not always wait for staff to assist him. Although interviews revealed R1 seemed unsteady at times, and that staff would ask R1 to wait for a staff to be with him, R1 was seen multiple times ambulating in his prosthetics, with a walker, without incident. By all witness accounts, R1 was cognitive and understood staff directions.

As a result of this case management, there is not a preponderance of evidence to conclude R1 sustained injury due to staff’s neglect and lack of care and supervision. No citations are issued as a result. An exit interview was conducted with Administrator and a copy of this report was provided to Administrator

SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC809 (FAS) - (06/04)
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