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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700527
Report Date: 05/10/2023
Date Signed: 06/21/2023 11:05:49 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/10/2023 and conducted by Evaluator Renee Campbell
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230210131718
FACILITY NAME:BALANCE ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
392700527
ADMINISTRATOR:MELISSA ORELLOFACILITY TYPE:
740
ADDRESS:1321 S FAIRMONT AVENUETELEPHONE:
(209) 334-3436
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:145CENSUS: 68DATE:
05/10/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Megan Moore, Culinary DirectorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility failed to observe change
Facility failed to seek timely medical care
INVESTIGATION FINDINGS:
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On 05/10/23, Licensing Program Analyst (LPA) Renee Campbell made an unannounced complaint visit to this facility at approximately 11:00 am. LPA Campbell was met by Megan Moore, Culinary Director and explained the reason for the visit.

Based on a review of documentation and interviews, it was established that the facility did not observe or report changes to R1’s condition. On 1/23/2023, R1's daughter, and home health visited R1 and noticed that R1 was unresponsive, speech was slurred, incomprehensible and “garbled”,unable to awake. Home Health along with R1’s doctor also noticed a change despite a lack of daily visits.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.
Document amended on 05/18/23 and 05/31/23 to maintain confidentiality.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Emerita CurielTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20230210131718
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/16/2023
Section Cited
CCR
87466
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87466 Observation of Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs... This requirement was not met as evidence by:
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Licensee will provide further training to improve observation of clients, provide a curriculum of the training and provide a signed roster of attendance and send it to LPA via email at renee.campbell@dss.ca.gov by POC date.
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based on observation and interview, the Licensee did not notice or identify changes in weight, speech and unresponsiveness
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Type B
05/18/2023
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: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/10/2023 and conducted by Evaluator Renee Campbell
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230210131718

FACILITY NAME:BALANCE ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
392700527
ADMINISTRATOR:MELISSA ORELLOFACILITY TYPE:
740
ADDRESS:1321 S FAIRMONT AVENUETELEPHONE:
(209) 334-3436
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:145CENSUS: 65DATE:
05/10/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Megan Moore, Culinary DirectorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident sustained pressure injuries while in care
Resident lost a significant amount of weight
Facility failed to notify family and physician of changes
Lack of care / supervision resulting in sepsis and amputation
INVESTIGATION FINDINGS:
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On 05/10/23, Licensing Program Analyst (LPA) Renee Campbell arrived at the facility unannounced to deliver findings related to a complaint regarding the above listed allegations. LPA Met with Megan Moore and explained the purpose of today’s visit.
During the course of the investigation, the Department reviewed records included but not limited to, hospital records, client records, facility documents and interviews. In regards to the allegation that resident sustained pressure injuries while in care, both home health and R1’s doctors, reported that the pressure wounds and the amputation, were a side effect of his health condition and were exacerbated by R1’s noncompliance, not staff. Facility staff also continued to keep R1’s family informed of any changes as shown by R1’s IR’s. Because R1 refused to be weighed, allegations that R1 lost a significant amount of weight cannot be held against the facility because there is no record of R1's weight before coming to the facility.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Emerita CurielTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3