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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700527
Report Date: 12/13/2022
Date Signed: 12/13/2022 03:51:24 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
11/23/2022 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20221123084042
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
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Marlene BremerTIME COMPLETED:
01:19 PM
ALLEGATION(S):
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Facility staff did not seek medical attention in a timely manner for resident in care.
Facility is not communicating with authorized representative.
INVESTIGATION FINDINGS:
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On 12-13-22 at 10:15am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue investigation and deliver findings for the complaint allegations noted above. 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. During this investigation, LPA conducted interviews with Administrator, 7 staff members, and resident1 (R1). LPA also reviewed facility file documentation including Physician’s reports, hospital notes, needs and service plan, medication log sheet, incident report, and staff communication records all pertaining to R1.

Allegation #1: Facility staff did not seek medical attention in a timely manner for resident in care. LPA interviewed Administrator, Staff1 (S1)-S7 and reviewed facility file documentation as stated above. Based on interviews and record reviews it was determined that R1 was sent to the hospital on 11-23-22 due to concerns involving blood in the urine. Based on hospital notes, R1 suffered from a bladder infection and treated accordingly with prescribed medication. {Cont. on 9099C}
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20221123084042
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: 12/13/2022
NARRATIVE
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 It was further revealed through interviews that R1 had episodes of discoloration and blood in the urine beginning 11-13-22 without evidence of an attempted medical follow up until 11-23-22. Additionally, it was revealed through record reviews and interviews that R1 has a history of bladder infections. Based on interviews and records reviewed, it is determined that facility did not seek timely medical attention after facility staff discovered a medical need for R1. As a result, this allegation is SUBSTANTIATED.

Allegation #2: Facility is not communicating with authorized representative. LPA interviewed Administrator, Staff1 (S1)-S7 and reviewed facility file documentation as stated above. Based on interviews and record reviews it was determined that R1 was sent to the hospital on 11-23-22 due to concerns involving blood in the urine. Based on hospital notes, R1 suffered from a bladder infection and treated accordingly with prescribed medication. It was further revealed through record reviews and interviews that R1 had episodes of discoloration and blood in the urine on 11-13-22, and without evidence of communication to R1’s responsible person until 11-19-22, when R1’s responsible person was attempted to be notified. Additionally, there is no evidence of R1's physician notified of R1's condition per regulatory requirements. R1 was sent to hospital on 11-23-22 for follow up according to record reviews. As a result, there is a preponderance of evidence to conclude R1’s responsible person and physician were not adequately notified of R1’s condition, therefore, the above allegation is SUBSTANTIATED.

As a result of investigation, 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 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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20221123084042
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: 12/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/14/2022
Section Cited
CCR
87465(a)(1)
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87465(a)(1) Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility…(1) The licensee shall arrange, or assist in arranging, for medical…care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by:
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Licensee will ensure staff training on importance of timely medical attention and submit proof of completed training to LPA. Licensee to submit training date to LPA by POC due date and proof of completed training to LPA no later than 2 weeks from date of citation issuance.
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Based on interviews and record reviews licensee did not ensure appropriate timely medical attention after discovery of discoloration and blood in urine. This posed an immediate health and safety risk to resident in care.
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Type B
12/27/2022
Section Cited
CCR
87466
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Observation of the resident…When changes such as…deterioration of…a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by:
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Licensee will read regulation 87466 and submit a signed declaration of understanding to LPA by POC due date.

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Based on interviews and record reviews, licensee did not notify physician upon discovery of blood in the urine on 11-13-22 and did not notify responsible person until 11-19-22. This posed a potential health and safety risk to resident in care.
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Licensee will ensure staff training on importance of communication to responsible persons and physicians regarding changes in resident’s medical status, and submit proof of completed training to LPA by POC due date.
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
LIC9099 (FAS) - (06/04)
Page: 3 of 3