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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700527
Report Date: 05/25/2023
Date Signed: 05/25/2023 04:47:27 PM


Document Has Been Signed on 05/25/2023 04:47 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:RODRIGUES, JUDYFACILITY TYPE:
740
ADDRESS:1321 S FAIRMONT AVENUETELEPHONE:
(209) 334-3436
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:145CENSUS: 64DATE:
05/25/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Rebecca AlbertTIME COMPLETED:
05:00 PM
NARRATIVE
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On 5/25/23 at approximately 2:30pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management for deficiencies found during the course of an investigation for complaint # 27-AS-20221223133411. LPA Jensen met with Program Director Rebecca Albert and explained the purpose of today's visit. LPA Jensen also spoke to current Administrator Judy Rodrigues and Owner/Operator Sunny Saini by telephone and explained the purpose of today's visit.

During the course of the investigation in to complaint # 27-AS-20221223133411, the Department conducted interviews with staff, clients, responsible parties and medical providers. The Department also reviewed facility records, Home Health Agency Records and medical records. It was determined based on Home Health Agency documentation that Resident 1 (R1) suffered from 5 pressure injuries. 1 of 5 pressure injuries was staged at level 3. According to interviews with Home Health Agency nurse (N1), facility staff was aware of the staging of R1's pressure injuries. N1 also stated that there was a delay in R1's family contacting a wound specialist or sending R1 to the emergency room because of the pressure injuries.

During the course of an interview with staff 7 (S7), the Department investigator was advised that R1 was always in pain however the Responsible Party (RP) for R1 would only allow the facility staff to give R1 Tylenol. When R1 would have a violent outburst he would hit the railing on his bed. She further stated that R1 would communicate that he was in pain by screaming. If facility staff moved his legs he would scream in pain. When asked if R1 should have been sent to the hospital sooner when facility staff observed him with a swollen wrist she replied yes however matters were complicated by the fact that if 911 needed to be called the facility would have to notify the RP first and the RP would always refuse to send R1 to the emergency room.

Continued on LIC 809C....
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2023
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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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
VISIT DATE: 05/25/2023
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Continued from LIC 809...
Staff 2 (S2) was also interviewed and advised that R1 was sent out to the hospital for hand swelling but had appeared to be in more pain than usual for about 2 weeks prior to getting sent out. S2 stated that R1 would scream out in order to communicate he was in pain and screamed more in the two weeks leading up to being sent out. S2 also stated that R1 was not sent out to the hospital sooner because R1's Responsible Party (RP) always wanted to be notified if there was a problem and then she would make the decision if a 911 call was needed, not facility staff. The policy was changed since and staff now calls 911 first then notifies family afterwards due to the problems encountered with R1. Staff 3 (3) and Staff 4 (S4) also stated that R1 should have been sent to the hospital sooner during their interviews.

A record review of R1's Needs and Service Plan dated 1/4/22 was not signed and did not address wound care or pain management despite the fact that the facility was aware R1 had pressure injuries.

Deficiencies are being cited from the California Code of Regulations (CCR) Title 22.

An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 05/25/2023 04:47 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: 05/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/26/2023
Section Cited
CCR
87615(a)(1)

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a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:

(1) Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by:
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The Licensee agrees to develop a plan of correction by 5/26/23 and email the plan for Department approval by 5/26/23 to maja.jensen@dss.ca.gov.
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Based on interviews with facility staff, a Home Health Agency Nurse and Home Health Agency records teh facility retained a resident with stage 3 pressure wounds. This poses an immediate risk to the health, safety and personal rights of residents in care
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Type A
06/01/2023
Section Cited
CCR87405(h)(5)

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Administrator - Qualifications and Duties

he administrator shall have the responsibility to: ...
Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs...This requirement was not met as evidenced by:
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The Licensee agrees to develop a plan of correction by 5/26/23 and email the plan for Department approval by 5/26/23 to maja.jensen@dss.ca.gov.
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Based on interviews conducted and records reviewed the facility retained a resident who's needs could not be met and did not make provisions for pain management and medical attention needed. This poses an immediate threat to the health, safety and personal rights of 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: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 05/25/2023 04:47 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: 05/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/01/2023
Section Cited
CCR
87463(a)(3)

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Reappraisals

he pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. This requirement was not met as evidenced by:

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The Licensee agrees to develop a plan of correction by 6/1/23 and email the plan for Department approval by 6/1/23 to maja.jensen@dss.ca.gov.
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This requirement was not met as evidenced by a review of R1's Needs and Service Plan did not address wound care or pain management. This poses a potential risk to the health, safety and personal rights of 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: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2023
LIC809 (FAS) - (06/04)
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