392700527-2-7-2023-27-AS-KHOS-CPFQD7-20230227110417

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700527
Report Date: 02/07/2023
Date Signed: 02/07/2023 03:29:45 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
09/06/2022 and conducted by Evaluator Jason Lund

COMPLAINT CONTROL NUMBER: 27-AS-20220906114200

FACILITY NAME:	BALANCE ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	392700527
ADMINISTRATOR:	AGUILAR, DAISY		FACILITY TYPE:	740
ADDRESS:	1321 S FAIRMONT AVENUE		TELEPHONE:	(209) 334-3436
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY:	145	CENSUS:	DATE:	02/07/2023
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Executive Director Melissa Orello		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Facility a/c is in disrepair

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jason Lund arrived at the facility unannounced to complete a complaint investigation regarding the above allegation. LPA Lund meet with Executive Director Melissa Orello and explained the reason for the visit.
Facility a/c is in disrepair - LPA Lund observed that the air conditioning was not working 9/9/2022 in the back assisted living area of the facility. Staff did have portable air conditioning units throughout the back of the facility. The facility did also have hydration stations throughout the facility.
As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.

Substantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

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 4

Control Number 27-AS-20220906114200

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: 02/07/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/21/2023 Section Cited CCR 87303(b)	1 2 3 4 5 6 7	Maintenance and Operation: A comfortable temperature for residents shall be maintained at all times. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	LPA reviewed facility air conditioning that it was fixed.
	8 9 10 11 12 13 14	LPA Lund observed that the air conditioning was not working 9/9/2022 in the back assisted living area of the facility.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
09/06/2022 and conducted by Evaluator Jason Lund

COMPLAINT CONTROL NUMBER: 27-AS-20220906114200

FACILITY NAME:	BALANCE ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	392700527
ADMINISTRATOR:	AGUILAR, DAISY		FACILITY TYPE:	740
ADDRESS:	1321 S FAIRMONT AVENUE		TELEPHONE:	(209) 334-3436
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY:	145	CENSUS:	DATE:	02/07/2023
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Executive Director Melissa Orello		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Residents rooms are dirty

Staff are barricading residents in on the memory care side

Staff left residents in soiled diapers for an extended period of time

INVESTIGATION FINDINGS:

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Residents rooms are dirty- LPA Lund reviewed facility records interviewed staff and residents in care. LPA observed facility residents’ rooms and interviews with residents in care and the room were clean and good repair.

Based on observation, facility records review, clients and staff interviews on the information provided, it was unclear if residents rooms are dirty therefore the allegation was deemed UNSUBSTANTIATED.

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20220906114200

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: 02/07/2023

NARRATIVE

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Staff are barricading residents in on the memory care side- LPA Lund interviewed staff and observed the memory care unit. LPA observed the all exits were cleared and working proper.

Based on observation and staff interviews on the information provided, it was unclear if staff are barricading residents in on the memory care side therefore the allegation was deemed UNSUBSTANTIATED.

Staff left residents in soiled diapers for an extended period of time- LPA Lund reviewed records, interviewed staff and witnesses. Interviews with staff check the residents in care according to the residents needs and services plans.

Based on records revidew, staff, witnesses’ interviews on the information provided, it was unclear if staff left residents in soiled diapers for an extended period of time therefore the allegation was deemed UNSUBSTANTIATED.

As a result of this investigation, this Department finds the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.
Exit interview was conducted with Executive Director Melissa Orello and a copy of report was left along with a copy of the appeal rights.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4