<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700527
Report Date: 10/29/2024
Date Signed: 10/29/2024 12:06:41 PM

Document Has Been Signed on 10/29/2024 12:06 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/
DIRECTOR:		AGUILAR, JONATHANFACILITY TYPE:
740
ADDRESS:1321 S FAIRMONT AVENUETELEPHONE:
(209) 334-3436
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 145TOTAL ENROLLED CHILDREN: 0CENSUS: 64DATE:
10/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Jonathan AguilarTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10-29-24 at 10:20am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding various resident to resident altercations. LPA met with Administrator Jonathan Aguilar and explained the purpose of the visit. LPA conducted brief interview with Administrator and reviewed resident records for resident1 (R1), R2, and R3. LPA also reviewed SOC 341 forms associated with these incidents.

Incident #1: On 10/11/24, based on record review and interview, a resident revealed that resident1 (R1) entered her room and grabbed her arms and shook her arms. This incident did not result in any visible markings or skin tears. Staff successfully separated both residents immediately. Facility staff completed a police report, notified licensing and ombudsman within regulatory time frames. Record review revealed R1's care plan has been updated to reflect history of resident to resident altercations and associated interventions in place.

Incident #2: On 10/23/24, based on record review and interview, it was revealed that while in a common area, resident2 (R2) made contact with another resident's left side of face and left upper arm which resulted in a small scratch and cut on resident's wrist area. Staff successfully separated both resident's immediately and were assessed by facility staff. The incident resulted in no major injuries or pain. Facility staff completed a police report and notification to licensing and ombudsman within regulatory time frames. Record review revealed R2's care plan is updated to reflect history of resident to resident altercations and is now currently placed on 1:1 supervision for safety.

Incident #3: On 10/24/24, based on record review and interview, it was revealed that resident3 (R3) made contact with another resident with a shoe. Staff were able to successfully intervene and separate residents to avoid further escalation. {Cont. on 809C}
Liza KingTELEPHONE: (650) 676-0442
Michael BilgerTELEPHONE: (916) 862-4722
DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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: 10/29/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Staff assessed both residents involved which did not reveal any injuries or pain. According to report submitted, R3 stated another resident was yelling at her which prompted the incident. Facility staff completed a police report and notification to licensing and ombudsman within regulatory time frames. Record review revealed R3's care plan has been updated to reflect recent history of resident to resident altercation and associated interventions in place.

All incidents described above took place in facility's memory care unit.

As a result of today's case management, no citations issued today. 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: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2