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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700527
Report Date: 01/06/2023
Date Signed: 01/06/2023 04:16:27 PM


Document Has Been Signed on 01/06/2023 04:16 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:MARLENE BREMERFACILITY TYPE:
740
ADDRESS:1321 S FAIRMONT AVENUETELEPHONE:
(209) 334-3436
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:145CENSUS: 62DATE:
01/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Nate KeyawaTIME COMPLETED:
04:26 PM
NARRATIVE
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On 1-6-23 at 3:00pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management regarding Administrator coverage follow up. LPA met with Community Relations Director Nate Keyawa and explained the purpose of the visit. Administrator Marlene Bremer was not present and notified via phone of LPA's presence. LPA reviewed current LIC 500 and interviewed Staff1 (S1) and S2. Based on records reviewed, interviews, and observation it was determined that certified Administrator was not on duty as required by the department based on a meeting held on 10-21-21 in which requirement was established. A review of LIC 500 revealed Administrator schedule as Tuesday through Saturday 9am-5:30pm. Based on interviews, it was revealed Administrator is on duty 2 days per week.

As a result of this case management, deficiencies are cited under Title 22, Division 6. A civil penalty in the amount of $250 is issued as a result of a repeat violation within a 12-month period. An exit interview was conducted with Nate Keyawa and a copy of this report was left with Nate. Appeal rights provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2023
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 01/06/2023 04:16 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: 01/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/13/2023
Section Cited

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Administrator Qualifications-Duties. (a) All facilities shall have a qualified and currently certified administrator...the Department may require that the administrator devote additional hours in the facility...when the need for such additional hours is substantiated by written documentation. This requirement is not met as evidenced by:
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Licensee will submit a plan of action to LPA outlining provisions for ensuring certified Administrator coverage at least 40 hours per week. Plan to be submitted to LPA by POC due date.
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Based on interview and record review, licensee did not ensure presence of a certified administrator at least 40 hour per week as required by the department during a meeting held on 10-21-21. This poses a potential health and safety risk to residents 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: 01/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2023
LIC809 (FAS) - (06/04)
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