392700527-8-9-2023-27-AS-RCAL-CUJSS4-20230809140719

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700527
Report Date: 08/01/2023
Date Signed: 08/09/2023 02:08:33 PM

Document Has Been Signed on 08/09/2023 02:08 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 CARE		FACILITY NUMBER:	392700527
ADMINISTRATOR:	RODRIGUES, JUDY		FACILITY TYPE:	740
ADDRESS:	1321 S FAIRMONT AVENUE		TELEPHONE:	2093343436
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY:	145	CENSUS: 59	DATE:	08/01/2023
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Facility Representatives, Judy Rodriguez		TIME COMPLETED:	12:00 PM

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A Non-Compliance Conference (NCC) was conducted on this day, 08/01/23, by the Sacramento South Regional Office via Teams meeting. This Noncompliance Conference was called to discuss the following issues or deficiencies: Care and Supervision, Incidental Medical Care, Personal Rights, Maintenance and Operation. Present in the meeting were:

NAME	TITLE
Stephenie Doub	Regional Program Manager
Czarrina Camilon-Lee	Licensing Program Manager
Josh Johnson Steven Ratcliff	Licensee, Atlantis Lodi, OPCO LLC Licensee, Atlantis Lodi, OPCO LLC
Sharon Wang Sunny Sain	Licensee, Atlantis Lodi, OPCO LLC Licensee, A1 Del Monte Lodi, INC
Anu Saini	Licensee, A1 Del Monte Lodi, INC
Chris Schuster	Vice President of Operations
Renee Campbell	Licensing Program Analyst

The Non-Compliance Conference process was explained during this meeting to include the Administrative Process. RM and LPM discussed the following citations and the associated plans of correction going forward. At this time, there are open complaints that have not been resolved.

SUPERVISOR'S NAME: Emerita Curiel	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee Campbell	TELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

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: 08/01/2023

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In the last three years, there have been 17 Type A deficiencies and 14 Type B deficiencies issued to the facility. These deficiencies include;

87405(a) Administrator Qualifications-Duties;

87464 {1)(1) Basic services

87466 Observation of the Resident

87211(.a)(l)(DJ Reporting Requirements

S7-165{a)(1) incidental MedicaI and Dental care

87468.1 (a)(2) Personal rights.

87303(el(2). Maintenance and Operation.

1569.69 c Other provisions. Licensee was unable to proviide a copy of facility fire drill.

87705 (c)(4)Care of Persons with Dementia. Resident found in another residents bed.

Licensee agreed to continue or implement the following :

1. Monthly and Weekly training for staff will continue (audit and training plans will be provided to LPA by 08/11/23)

2. Administrator will continue to be present at facility 40 hrs a week.

3. LIC 500 Staff Schedule will be provided to LPA by 08/11/23.

4. As stated by the administrator, a 100 percent of all residents care plans will be updated and completed by 09/01/23.

SUPERVISOR'S NAME: Emerita Curiel	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee Campbell	TELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

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: 08/01/2023

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5.Dementia residents will have updated 602’s within 2 weeks by 08/11/23.

6. A licensed architect will be engaged for the construction work with a plan to submit building permits by mid August 2023. Facility administrator to provide a copy of permits to CCL once obtained.

7. Licensee will continue to communicate with Management Company weekly.

8. Staff will receive yearly and additional dementia ongoing training as required.

ADDITIONAL ITEMS DISCUSSED:

1.The Licensee confirmed their acknowledgement and approval to change the facility name from Balance to DelMonte Assisted Living and Memory Care-Lodi.

2. The management company is requesting to approve the new Plan of Operation and Admission Agreement that was recently submitted. Suini advised that cameras have been installed in common areas as part of the new Plan of Operation. Please provide LIC999 Facility Sketch to indicate where cameras are located by 08/11/2023.

3. At the conclusion of this NCC, the facility representatives was advised that increased monitoring will be initiated and facility compliance will be re-evaluated in nine months.

SUPERVISOR'S NAME: Emerita Curiel	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee Campbell	TELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

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: 08/01/2023

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Community Care Licensing Department (CCLD) will do the following:

In the event that the Department determines that the licensee has violated the law/regulations or is inadequately implementing the approved plans, the Department, in its discretion, may seek formal legal action or other appropriate administrative action.

Completing the Non-Compliance Conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Code if such action is deemed necessary by the Regional Manager.

SUPERVISOR'S NAME: Emerita Curiel	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee Campbell	TELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

LIC809 (FAS) - (06/04)

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