392700527-4-21-2023-27-AS-LKIG-CRWJK8-20230517070644

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700527
Report Date: 04/21/2023
Date Signed: 04/21/2023 03:18:12 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
12/23/2022 and conducted by Evaluator Maja Jensen

COMPLAINT CONTROL NUMBER: 27-AS-20221223133411

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: 70	DATE:	04/21/2023
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Melissa Orello		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility did not adequately report change of condition to responsible party

INVESTIGATION FINDINGS:

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On 4/21/23 at 2:15pm Licensing Program Analysts (LPAs) Maja Jensen and Jennifer Fain arrived at facility unannounced to deliver findings related a complaint investigation surrounding the above listed allegation. LPAs met with Melissa Orello and explained the purpose of today's visit.

During the course of this investigation, the Department reviewed records including but not limited to resident file, personnel reports, medical records, and Home Health Nurse records.

The Department also conducted interviews with facility staff, facility residents, family members and medical professionals. As a result of the investigation conducted it was determined that Facility staff indicated that Resident 1 (R1) had swelling on his left hand for as long as a week prior to being sent to
the hospital on 12/22/2023. According to the responsible party (RP) for R1, facility staff 1 (S1) reported to the RP that R1’s hand was swollen on 12/20/2023. The RP and S1 indicated that S1 reported that R1'’s hand was swollen prior to 12/22/2023.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20221223133411

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: 04/21/2023

NARRATIVE

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Continued from LIC 9099...
On 12/22/2023, when facility staff reported to the RP that R1’s hand was swollen, they did not send R1 to the hospital until the RP went to the facility and called 911.

Multiple facility staff indicated that R1 would “scream” out to communicate that he was in pain. R1
screamed out more indicating that he was in more pain than usual. Multiple facility staff stated that R1
should have been sent to the hospital sooner.

An attending physician (P1) at the Emergency Department stated that the injury R1 sustained would have been noticed based on the swelling and the fact that it was “tender to the touch.”

Based on the records reviewed and the interviews conducted the allegation of facility did not adequately report change of condition to responsible party is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met.

As result of the investigation conducted, furthermore it was discovered that the facility failed to seek timely medical attention for R1 thereby causing undue suffering..

The following deficiencies were observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22. A civil penalty in the amount of $500 is also being assessed

At the time of the complaint visit, the issuance of an Enhanced Civil Penalty was still being determined and the licensee was informed that a civil penalty might be assessed based on Health and Safety Code § 1569.49.

An exit interview was conducted and a copy of this report, appeal rights and confidential names list was provided.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20221223133411

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: 04/21/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/22/2023 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	Basic Services Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code Section 1569.2(c)...This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The Licensee agrees to conduct an in-service training and implement a new protocol wherein the Resident Care Director who is on call 24/7 will immediately be notifed of a change in condition. The Licensee will email proof of correction by POC due date.
	8 9 10 11 12 13 14	Based on interviews conducted and records reviewed the facility failed to seek timely medical attention which resulted in R1's undue suffering. This poses an immediate risk to the health, welfare, and personal rights of residents in care.	8 9 10 11 12 13 14
Type B 04/22/2023 Section Cited CCR 87466	1 2 3 4 5 6 7	Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or 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:	1 2 3 4 5 6 7	The Licensee agrees to conduct an in-service training and implement a new protocol wherein the Resident Care Director who is on call 24/7 will immediately be notifed of a change in condition. The Licensee will email proof of correction by POC due date.
	8 9 10 11 12 13 14	Based on interviews conducted and records reviewed R1 displayed increased signs of pain and had visible swelling however the facility did not notify the responsible party in a timely manner. This poses a potential health, safety and personal rights 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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

LIC9099 (FAS) - (06/04)

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