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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 03:55:12 PM


Document Has Been Signed on 12/13/2022 03:55 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 - IncidentUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Marlene BremerTIME COMPLETED:
04:00 PM
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On 12-13-22, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding incident reports dated 8-5-22, 8-31-22, 9-29-22, and 10-21-22. 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. Based on review of incident reports, it was determined that Resident1 (R1) and R2 experienced. unwitnessed falls. Reports indicates 9-1-1 was called for medical intervention upon discovery of falls, and appropriate responsible party members were notified as well. An observation of facility revealed fall preventive measures are in place including operative call pendants. A review of staffing records on 8-5-22, 8-31-22, and 9-29-22 revealed appropriate staffing levels were in place at time of incidents.

On 10-21-22, it was reported that R3 sustained a stage 3 pressure sore on tailbone. Through record review, it was determined that R3 was on hospice with wound care orders and proper interventions in place per regulatory requirements. Hospice waiver is in place for facility.

Based on today’s case management, no deficiencies are cited today. An exit interview was conducted with Marlene Bremer and a copy of this report was left with Marlene.

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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