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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700527
Report Date: 07/07/2023
Date Signed: 07/07/2023 11:36:56 AM


Document Has Been Signed on 07/07/2023 11:36 AM - 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:
07/07/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
07:30 AM
MET WITH:Judy Rodrigues, AdministratorTIME COMPLETED:
12:00 PM
NARRATIVE
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On 07/07/2023, Licensing Program Analyst (LPA) Renee Campbell and Victoria Brown arrived at 7:30 am at the facility. LPA's met with representatives from the Fire Department (FD) and Community Development (CD) and facility representatives of Atlantis Lodi OPCO LLC;A1 Del Monte Lodi INC Sunny Saini, Licensee, and Anu Saini President to conduct a tour of the facility and observe the health and safety of the residents. The team toured the facility and identified areas of concern due to construction that was started without proper documentation.
Based on observations, photos were taken of areas that need to be corrected and/or removed. Per FD and CD, the following items must be completed by the end of day:
-Remove front doors
-Remove all debris from outside of physical plant
-Replace non-functioning exit signs and change to appropriate direction
-Ensure proper ventilation of framed construction area in lobby
-Remove wood fencing from authorized exit area.

In addition, Licensee shall obtain the services of a certified licensed :
-Electrician
-Contractor
-Architect
-Fire Alarm Contractor
-City permit

LPA's observations further found no notification to the public of ongoing construction:
-Post Under Construction Signs visible to the public.
SUPERVISOR'S NAME: Emerita CurielTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023
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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: BALANCE ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 392700527
VISIT DATE: 07/07/2023
NARRATIVE
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Based on the teams observation and a review of facility file, and confirmation from facility representatives, a city permit was not obtained. In addition, Community Care Licensing was not informed of the facilities intent prior to construction.

The facility will be cited deficiencies and an immediate civil penalty in the amount of $500.00 shall be assessed today for violations. The Licensee was provided a copy of the issued immediate civil penalty (LIC421FC) during this visit.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; additional civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted and a copy of the report given.
SUPERVISOR'S NAME: Emerita CurielTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/07/2023 11:36 AM - 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
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: 07/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/07/2023
Section Cited
CCR
87305(a)

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Alterations to Existing Building or New Facilities
Prior to construction or alterations, all facilities shall obtain a building permit.
This requirement is not met as evidenced by: ,
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Licensee/Representatives of the facility shall:
-Remove front doors. -Remove all debris from outside of physical plant. -Replace non-functioning exit signs and change to appropriate direction. -Ensure proper ventilation of framed construction area in lobby
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Based on observation and interviews, the licensee/representatives of the facility confimed they did not obtain a permit prior to construction.
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-Remove wood fencing from authorized exit area.
You are hereby issued an immedicate civil penalty in the amount of $500. Please submit photos of corrected deficiencies via email to renee.campbell@dss.ca.gov by POC due date.

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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: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 07/07/2023 11:36 AM - 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
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: 07/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/07/2023
Section Cited
CCR
87211(a)(1)(D)

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Reporting Requirements
Any incident which threatens the welfare, safety or health of any resident...


This requirement is not met as evidenced by:
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The licensee/representatives shall post hazard signs & email a letter stating regulations will be followed and CCL will be notified timely of any changes regarding the physical plant, documentation and/or residents. Images & letter will be emailed to renee.campbell@dss.ca.gov by POC due date.
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Based on observations the licensee/representatives did not submit a notification to Community Care Licensing (CCL) regarding new construction in the facility.
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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: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023
LIC809 (FAS) - (06/04)
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