392700527-4-21-2023-27-AS-LKIG-CRWJK9-20230517070644

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700527
Report Date: 04/21/2023
Date Signed: 04/21/2023 03:26:56 PM

Unsubstantiated

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:	03:30 PM

ALLEGATION(S):

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Neglect/Lack of Care and Supervision resulting in resident sustained fractured wrist while in care

INVESTIGATION FINDINGS:

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On 4/21/23 at XXX 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 XXX 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. On 12/22/2023, On 12/22/22 the responsible party (RP) for Resident 1 (R1) received a text message from facility staff at approximately 1200 hours indicating that R1 had swelling in his hand. Later in the day, home health, and the RP visited R1. The RP called 911 at the direction of home health staff. R1 was transported to Kaiser Permanente Emergency Room with a chief complaint of a swelling on left hand. R1 was examined and x-rays were taken. .

Unsubstantiated

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...
R1 was diagnosed with localized swelling on left hand and possible non-displaced left triquetrum fracture.

Facility staff, home health staff or the RP for R1 were unable to state how the fracture of R1’s left wrist
occurred. They assumed it could be from him being combative or a fall, but no one witnessed or reported
anything. R1 was unable to verbalize or state how the fracture may have occurred. An attending physician
indicated that she could not determine how the left wrist fracture occurred.

As a result of being unable to determine how the fracture actually occurred the allegation of neglect/lack of care and supervision resulting in resident sustained fractured wrist while in care is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it.

An exit interview was conducted and a copy of this report along with appeal rights and a confidential names list was given.

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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