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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700527
Report Date: 11/18/2022
Date Signed: 11/18/2022 04:44:10 PM


Document Has Been Signed on 11/18/2022 04:44 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



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: 62DATE:
11/18/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Melissa OrelloTIME COMPLETED:
04:00 PM
NARRATIVE
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On 11-18-22 at 10:45am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a health and safety check. LPA met with Administrator Melissa Orello and explained the purpose of the visit. LPA conducted facility tour including common areas, resident rooms, dining area, kitchen area, and outside area to ensure compliance with Title 22 regulation. LPA also interviewed Administrator and staff1 (S1). Upon entry LPA was not screened immediately for COVID symptoms. LPA observed facility during tour to be sanitary with no foul odors detected. Carpets and walls were clean. Resident rooms had appropriate furniture and furnishing. Facility has adequate food supply on hand.

Water temperature was tested in assisted living and memory care side in various hallways with temperature ranging between 105*F and 120*F. LPA reviewed facility file documentation including maintenance log and recent replacement of water heater. Maintenance records indicate repair company was at facility on 11-14-22 to address a malfunctioning water heater which began on the weekend of 11-12-22 based on interviews conducted. Based on additional record reviews, facility did not notify licensing department within 24 hours of loss of hot water for a hallway section in assisted living.

Additionally, based on interviews, it was determined that administrator of record was not present in facility as of approximately middle October 2022 and new Administrator has been hired to act as interim Administrator of Record with no start date at this time. LPA also reviewed LIC 308 and LIC 500 and reviewed actual hours worked for designated substitute indicated on LIC 308. At this time, facility does not have an acting Administrator on duty 40 hours per week as required based on a department meeting held on 10/21/21. Additionally, based on today's visit and review of LIC 308 and LIC 500, facility did not have a designated substitute on duty.

Facility currently has 1 active COVID case on assisted living side who is currently isolated with precautions in place.. Licensing department did not receive report regarding COVID positive within 24 hours of occurrence. {Cont. on LIC 809C}
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022
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 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: BALANCE ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 392700527
VISIT DATE: 11/18/2022
NARRATIVE
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Based on today's visit, citations are cited under Title 22, Division 6 and Health and Safety Codes. An exit interview was conducted with Melissa Orello and a copy of this report was left with Melissa. Appeal rights provided. Melissa Orello, Administrator was not present at the conclusion of this case management for signing and designated culinary director Megan Moore to sign in her absence.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/18/2022 04:44 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/21/2022
Section Cited

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Administrator Qualifications-Duties. (a) All facilities shall have a qualified and currently certified administrator...the Department may require that the administrator devote additional hours in the facility...when the need for such additional hours is substantiated by written documentation. This requirement is not met as evidenced by:
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Based on interview and record review, licensee did not ensure presence of a certified administrator at least 40 hour per week as required by the department during a meeting held on 10-21-21. This poses an immediate health and safety risk to residents in care.
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Type A
11/21/2022
Section Cited

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Personal rights. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not as evidence by:
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Based on observation, LPA was not screened for COVID precautions upon entry demonstrating facility's absence of following COVID safety protocol while active COVID exists in facility. This poses an immediate health and safety risk to resident's 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: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 11/18/2022 04:44 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/28/2022
Section Cited

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Reporting requirements. (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(D)Any incident which threatens the welfare, safety or health of any resident...This requirement was not met evidence by:
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Based on interview and record review, faclity's hot water heater malfunctioned during the weekend of 11/12/22 and was not reported to licensing within 24 hours. Additionally, facility experienced COVID-19 cases which were not reported to Licensing per regulatory requirements. This poses a potential health and safety risk to residents in care.
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Type B
11/28/2022
Section Cited

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Administration and Management. (b) At least one administrator, facility manager, or designated substitute who is at least 21 years of age and has qualifications adequate to be responsible and accountable for the management and administration of the facility...shall be on the premises 24 hours per day. This requirement is not as evidenced by:
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Based on interview and record review, facility did not have a facility manager or designated substitute on duty 24 hours per day as specified on LIC 500 and LIC 308. This poses 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: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4