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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700527
Report Date: 06/02/2023
Date Signed: 06/03/2023 01:32:06 PM


Document Has Been Signed on 06/03/2023 01:32 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
SACRAMENTO AC/SC, 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:
06/02/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Megan Moore, Culinary DirectorTIME COMPLETED:
04:45 PM
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On 06/02/23, Licensing Program Analyst Renee Campbell arrived unannounced at the facility and met with Megan Moore regarding deficiencies recorded on 05/10/23.

The investigation was the result of the facility's failure to provide timely medical care and lack of observation. During the course of this investigation, the Department conducted interviews with staff, clients and a client family member. The Department also reviewed records including but not limited to facility and medical records.

As part of their plan of correction, staff were to provide proof of further training on 05/16/23 and a signed declaration of understanding by 05/18/23. Due to communication issues with new ownership, neither were provided. After discussion with staff during this visit, LPA Campbell received proof of the training. Though current Administrator Judy Rodrigues agreed to provide the signed and dated declaration the next business day, it has been recited.

Due to time limits, LPA Campbell was unable to complete this report on sight and the Culinary Director Megan Moore agreed to sign and return this document hard copy the next day on 06/03/23.

No further deficiencies cited.
SUPERVISOR'S NAME: Emerita CurielTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2023
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 06/03/2023 02:05 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/03/2023 02:02 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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: 06/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/09/2023
Section Cited
CCR
87465(a)(2)

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87465(a)(2) Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by
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Administrator will review regulation 87465(a)(2) and submit a signed declaration of understanding to LPA and provide the facility procedure for when to contact 911 by POC date.
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based on interviews and record reviews, due to unreported changes in condition by staff, the doctor was not notified of behavioral changes and 911 was therefore not called for R1.
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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: Emerita CurielTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2023
LIC809 (FAS) - (06/04)
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