392700527-11-3-2020-27-AS-KHOS-BV3K22-20201105063025

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700527
Report Date: 11/03/2020
Date Signed: 11/03/2020 10:24:58 AM

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
03/17/2020 and conducted by Evaluator Stephenie Doub

COMPLAINT CONTROL NUMBER: 27-AS-20200317145909

FACILITY NAME:	BALANCE ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	392700527
ADMINISTRATOR:	ORELLO, MELISSA		FACILITY TYPE:	740
ADDRESS:	1321 S FAIRMONT AVENUE		TELEPHONE:	(209) 334-3436
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY:	145	CENSUS: 69	DATE:	11/03/2020
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Melissa Orello, Administrator		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff are not providing medications as prescribed.
Facility staff are administering medications beyond their scope of practice.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Stephenie Doub contacted the facility on this day to conclude a complaint investigation via telephone due to COVID-19 and pre-cautionary measures. LPA spoke with Administrator (AD) Melissa Orello and discussed the purpose of the call and the elements of the allegations.

The initial 10-day visit was conducted on 3/24/2020. LPA interviewed Administrator, Staff 1 and Staff 2. LPA also reviewed incident reports and medication records for Resident 1 (R1), Resident 2 and Resident 3. LPA interviewed Resident 1 (R1). AD Orello and staff interviewed denied medications not being given as prescribed. R1 reported multiple instances where medications were not administered as prescribed. LPA reviewed medications records and observed dates where medications were not noted to be administered. Based on information provided through interviews and documentation, there was a preponderance of evidence to prove the allegation occurred, therefore the allegation was deemed SUBSTANTIATED.
(continued)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Stephenie Doub	TELEPHONE: (916) 767-4231
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020

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-20200317145909

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: 11/03/2020

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(continued from page 1) It was alleged that facility staff were administering medications beyond their scope of practice. The facility submitted an incident report noting that staff administered medication beyond their scope of practice. It was noted that a staff member administered liquid medications that was not pre-filled by a skilled professional. Based on documentation, the allegation that staff were administering medications beyond their scope of practice was SUBSTANTIATED.

This agency has investigated the allegations noted. We have found that there was a preponderance of evidence to prove that the allegations occurred as reported, therefore the allegations were deemed substantiated. An exit interview was conducted with AD Orello via telephone. A copy of this report along with confidential names list and appeal rights was provided. An electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Stephenie Doub	TELEPHONE: (916) 767-4231
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20200317145909

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: 11/03/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/04/2020 Section Cited CCR 87633(j)(1)	1 2 3 4 5 6 7	Hospice Care of Terminally Ill Residents In caring for a resident's health condition, facility staff, other than appropriately skilled health professionals, shall not perform any health care procedure that under law may only be performed by an appropriately skilled professional,	1 2 3 4 5 6 7	Administrator stated that she has retrained all medtechs regarding administration of medications. Proof of training will be provided to CCL by the POC date of 11/4/2020.
	8 9 10 11 12 13 14	This regulation was not met as evidence by: Licensee did not ensure staff did not perform any procedures that can only be performed by a skilled professional. Based on documentation staff administered liquid medication that was not pre-drawn. This poses an immediate risk to residents in care.	8 9 10 11 12 13 14
Type A 11/04/2020 Section Cited CCR 87465(a)(5)	1 2 3 4 5 6 7	Incidental Medical and Dental Care. A plan for incidental medical and dental care shall be developed...and provide for assistance in obtaining such care, by compliance with the following: (5) The licensee shall assist residents with self-administered medications as needed.	1 2 3 4 5 6 7	Administrator will provide a plan for auditing of medication records to ensure medications are being given a prescribed. Proof of correction will be provided to CCL by the POC date of 11/4/2020.
	8 9 10 11 12 13 14	This regulation was not met as evidence by: Licensee did not ensure that residents were assisted with self-administration of medications. Based on documentation and interviews, medications were not administered per physician's orders. This poses an immediate risk to residents in care.	8 9 10 11 12 13 14

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: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Stephenie Doub	TELEPHONE: (916) 767-4231
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020

LIC9099 (FAS) - (06/04)

Page: 3 of 3