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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700527
Report Date: 04/21/2022
Date Signed: 04/21/2022 12:14:35 PM

Unsubstantiated


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
04/13/2022 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20220413135126
FACILITY NAME:BALANCE ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
392700527
ADMINISTRATOR:AGUILAR, DAISYFACILITY TYPE:
740
ADDRESS:1321 S FAIRMONT AVENUETELEPHONE:
(209) 334-3436
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:145CENSUS: 59DATE:
04/21/2022
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Daisy AguilarTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Illegal Eviction
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 4/21/22 at 9:20am Licensing Program Analyst Maja Jensen arrived at facility to open a complaint investigation into the above allegation. LPA Jensen met with Executive Director Daisy Aguilar and explained the purpose of today's visit.

LPA Jensen conducted an interview with Resident 1 (R1), staff 1 (S1) and staff 2 (S2). LPA Jensen also reviewed the Eviction letter, The house rules signed as part of the admission agreement, the resident file, the LIC 602, chart notes from a pysician visit and the needs and service plan. The eviction letter was observed to contain all required regulatory elements. Based on a preponderence of evidence the resident engaged in an action that would be in violation of the house rules and that would pose a potential health and safety risk to residents in care. The allegation of illegal eviction is UNSUBSTANTIATED.

No deficiencies were cited from the California Code of Regulations, Title 22, during the course of this visit. An exit interview was conducted and a copy of this report was given to the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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