392700527-12-2-2022-27-AS-KHOS-CLWUQS-20221208144736

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700527
Report Date: 12/02/2022
Date Signed: 12/02/2022 01:27:36 PM

Substantiated

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
11/17/2022 and conducted by Evaluator Michael Bilger

COMPLAINT CONTROL NUMBER: 27-AS-20221117081654

FACILITY NAME:	BALANCE ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	392700527
ADMINISTRATOR:	AGUILAR, DAISY		FACILITY TYPE:	740
ADDRESS:	1321 S FAIRMONT AVENUE		TELEPHONE:	(209) 334-3436
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY:	145	CENSUS: 61	DATE:	12/02/2022
		UNANNOUNCED	TIME BEGAN:	10:27 AM
MET WITH:	Marlene Bremer		TIME COMPLETED:	01:26 PM

ALLEGATION(S):

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Licensee did not ensure that facility faucets deliver hot water

INVESTIGATION FINDINGS:

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On 12-2-22 at 10:27am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue investigation and deliver findings for the allegation noted above. LPA met with Administrator Marlene Bremer and explained the purpose of the visit. During this investigation, LPA conducted a facility observation on 11/18/22 and interviewed Staff1 (S1) and acting Administrator. LPA also reviewed repair records for water heater dated 11-14-22 and conducted additional interview with service repair company. Further interviews with S2, S3, Resident1 (R1) and R2, as well as Administrator were conducted on 12-2-22.
Based on interviews, record reviews, and observation, it was determined that facility’s water heater malfunctioned on 11-11-22 resulting in faucets not delivering hot water within a hallway of the assisted living section. It was further revealed that service repair company was notified on 11-14-22 at 11:24am to address the absence of hot water coming from faucets. Furthermore, it was revealed that facility was utilizing a residential water heater which was deemed unsuitable according to service repair company records and was replaced accordingly as part of the repair order. {Cont. on 9099C}

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022

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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Control Number 27-AS-20221117081654

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/02/2022

NARRATIVE

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Based on interviews conducted, during the course of time when faucets were not delivering hot water, facility was accommodating various residents to vacant rooms for showering and bathing needs. After water heater was assessed by service company, it was determined that water heater required replacement which was completed on 11-17-22.

It is determined based on the above events that facility had knowledge of faucets not delivering hot water to various residents in care. Based on service company’s website review, service company utilized is available for inquiries 24 hours per day, 7 days per week.
As a result, there is a preponderance of evidence to conclude facility did not adequately act to ensure various faucets delivered hot water after the discovery of the malfunction on 11-11-22 and calling service repair company on 11-14-22, as well as not ensuring an appropriate water heater in place for facility. Therefore, this allegation is SUBSTANTIATED. Citations are issued under Title 22, Division 6, Chapter 8 and noted on LIC 9099D.

An exit interview was conducted with Marlene Bremer and a copy of this report was left with Marlene. Appeal rights provided.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20221117081654

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/02/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/12/2022 Section Cited CCR 87303(e)(2)	1 2 3 4 5 6 7	87303(e)(2). Maintenance and Operation. (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water… This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee will develop and submit a plan ensuring the appropriate functionality of water faucets throughout facility. Plan to include an audit of all facility faucets and water heaters to ensure proper functionality. Plan to be submitted to LPA by POC due date.
	8 9 10 11 12 13 14	Based on interview and record review, facility faucets in a section of assisted living rooms were not delivering hot water to residents in care beween 11-11-22 and 11-17-22. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022

LIC9099 (FAS) - (06/04)

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