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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700527
Report Date: 07/09/2023
Date Signed: 07/09/2023 02:36:35 PM


Document Has Been Signed on 07/09/2023 02:36 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:
07/09/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:52 AM
MET WITH:Megan MooreTIME COMPLETED:
02:45 PM
NARRATIVE
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LPA Johnson arrived and met with M. Moore, who assisted LPA with the visit. LPA toured the facility. LPA was later joined by the Administrator via phone.

The purpose of this visit was a health and safety check from the inspection on 7/7/2023. LPA was able to verify that the requested plans appear to be corrected, however, the assigned LPA for this facility will confirm and clear the deficiencies at a later date.

During the inspection LPA observed a medication cart unlocked in the hallway without staff present. LPA inspected the kitchen and observed the Ansul or fixed system is out of compliance with the state fire marshal requirement (last service 2021)

As a result of this visit deficiencies were observed and cited with civil penalties. Per Title 22 Regulations, Division 6 /CA. Health and Safety codes.

Exit interview conducted and appeal rights given.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 07/09/2023 02:36 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: 07/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/10/2023
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 by: Observation.
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Administrator shall arrange for the systems to be serviced/re-inspected. Licensee/Administrator shall send a picture of the new tags as proof. By POC date.

**Fire Clearance Civil Penalty Assessed****
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The facility failed to maintained in conformity with the regulations adopted by the State Fire Marshal. The "Fixed System" in the kitchen (photo taken) outdated. This system is scheduled for a semi-annual maintenance and was last serviced on 8/29/2021. Posing an immediate health and safety risk to residents
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Type A
07/10/2023
Section Cited
CCR87465(h)(2)

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87465(h)(2) Incidental Medical and Dental Care. The following requirements shall apply to medications which are centrally stored: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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Med-Tech locked the carts during LPA's inspection. Administrator shall hold an in-service training with all staff about locking all medications when finished with them. Administrator shall send a date for the training by 7/10/23 and then shall submit training material used along with signature sheet of staff that attended to LPA.
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This requirement is not met by LPA observed unlocked medications cart in the hallway (photo taken). This poses an immediate health and safety risk to residents care.
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Via email or fax.
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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2