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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700527
Report Date: 12/13/2022
Date Signed: 12/13/2022 03:54:18 PM


Document Has Been Signed on 12/13/2022 03:54 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: 58DATE:
12/13/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Marlene BremerTIME COMPLETED:
02:45 PM
NARRATIVE
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On 12-13-22 at 1:45pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding reporting requirements. LPA spoke with Administrator Marlene Bremer via phone and explained the purpose of the visit. Administrator gave permission for culinary director (S8) to sign in her absence. LPA conducted interviews with Administrator and reviewed facility file documentation. During a complaint investigation regarding complaint # 27-AS-20221123084042 it was determined that resident1 (R1) was sent to the hospital on 11-23-22 due to concerns of blood in the urine. Based on facility file documentation reviews and department file reviews, it was revealed that facility did not submit an incident report to the department indicating the hospitalization of R1 on 11-23-22, or communication to responsible person and physician of R1.

As a result of today’s case management, citation issued under Title 22, Division 6, Chapter 8. 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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/13/2022 03:54 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: 12/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/27/2022
Section Cited

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87211(a)(1)(D) Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports as the Department may require…: (1) A written report shall be submitted to the licensing agency...within seven days of the occurrence of…(D) Any incident which threatens the...health of any resident…This requirement was not met as evidenced by:
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Licensee will read regulation 87211 and submit a signed declaration of understanding to LPA by POC due date.
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Based on facility file documentation reviews, licensee did not ensure the submission of an incident report to the department per regulatory requirements after a hospitalization of R1 due to blood in the urine. This posed a potential health, safety and resident rights risk to resident 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: 12/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2022
LIC809 (FAS) - (06/04)
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