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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700527
Report Date: 07/12/2023
Date Signed: 07/13/2023 01:04:47 PM


Document Has Been Signed on 07/13/2023 01:04 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: 23DATE:
07/12/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Judy Rodrigues, AdministratorTIME COMPLETED:
12:15 PM
NARRATIVE
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On 07/12/23 at approximately 8 am, Licensing Program Analyst (LPA) Renee Campbell made an unannounced visit to tour the facility and observe the health and safety of the residents. LPA arrived to examine alterations and concerns regarding construction and to clear POC. The LPA met with Judy Rodrugues, Adminstrator and LPA Campbell reviewed areas of concern from the prior visit on 07/07/23. Chairs and table were found to still be present near the exit doors. Howerver the facility had removed the refrigerator. Once identified, staff relocated the items. When LPA Campbell walked around the outside the perimeter of the facility, halted construction was viewed. Though the Fire Marshall had stated that the patio/meeting room doors were to be removed and the room was to be left open since the construction was permitted, the facility had nailed plywood across the entrance. The Administrator had the boards taken down when requested.

When touring the Memory Care Area, LPA Campbell also observed that the door alarm had not been replaced as the Administrator reported would be done 07/07/23.
LPA did not observe POC to be cleared, therefore additional civil penalties will be assessed 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: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2023
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 07/13/2023 01:04 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
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: 07/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/12/2023
Section Cited
CCR
87203

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87203
Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic
This requirement is not met as evidenced by:
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Facility will remove panelling and furniture that obstructs exits immediately per fire department instructions on 07/07/23 as of POC date and LPA Campbell will examine removal by end of visit.
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Based on observation and review, the facility failed to maintain conformity with the regulations adopted by the State Fire Marshal as indicated by unpermitted construction closed off with wood panelling and failure to remove tables and chairs from near exit. Posing an immediate health and safety risk to residents
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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: 07/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2023
LIC809 (FAS) - (06/04)
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