392700527-10-25-2023-27-AS-KHOS-CX5QNG-20231031121907

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700527
Report Date: 10/25/2023
Date Signed: 10/25/2023 10:57:30 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/28/2023 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230728105712

FACILITY NAME:	BALANCE ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	392700527
ADMINISTRATOR:	RODRIGUES, JUDY		FACILITY TYPE:	740
ADDRESS:	1321 S FAIRMONT AVENUE		TELEPHONE:	(209) 334-3436
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY:	145	CENSUS: 70	DATE:	10/25/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Anu Saini and Neil Mehta and Dasiy Aguliar		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Resident sustained multiple injuries while in care as a result of inadequate
supervision.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 10/25/2023 at 9:00 AM to deliver complaint findings, LPA met with Anu Saini and Neil Mehta and Dasiy Aguilar and explained the purpose of the visit.

Throughout the course of this investigation, the Department conducted interviews and reviewed facility documents. It was learned resident 1 (R1) sustained serious bodily injuries due to being physically assaulted by resident 2 (R2) on July 22, 2023. At the time of the assault, there were two caregivers working, and both caregivers were not in the common area where the assault occurred. The investigation indicated the two caregivers were responsible for providing care and supervision to twenty-nine to thirty-three residents on the day of the assault. On October 03, 2023, staff interview, it was reported caregivers have a difficult time providing care in supervision in the common areas since there are other work duties that need to be completed. The investigation interviews also revealed the facility is understaffed and requires additional staff to meet the needs of all residents in care.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230728105712

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BALANCE ASSISTED LIVING AND MEMORY CARE	FACILITY NUMBER: 392700527
	VISIT DATE: 10/25/2023

NARRATIVE

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Moreover, R2 has a history of being verbally aggressive towards R1. In addition, R2 has thrown urine at R1. Facility staff are aware of R2’s aggressiveness towards R1, however, the facility has not implemented safety measures to keep R1 safe, and the facility failed to separate R1 from R2. Facility Caregivers have also reported R1 follows them around to prevent R2 from getting near them. The facility has shown itself to have a history of residents carrying out aggressive acts towards other residents. On August 16, 2023, Resident 3 (R3) was found pulling on resident 4’s (R4) arm. A second altercation occurred on September 30,2023. The altercation resulted in resident R3 sustaining a cut on the back of their head, which was caused by Resident 5 (R5). Local law enforcement was called to the facility during this altercation. On October 15, 2023, R4 inappropriately touched resident 6 (R6). As a result of the inappropriate touch, R6 slapped R4.

The facility’s lack of implementing safety measures to minimize the risk of altercations and assaults between residents, has resulted in residents sustaining serious injuries. In particular, R1 sustained an acute chronic intracranial subdural hematoma, a wrist fracture, and a humerus fracture from the July 22, 2023, assault. Additionally, R1 required skilled nursing care after being discharged from the hospital. An immediate $1000.00 civil penalty shall be assessed on October 25, 2023; based on the allegation: " Resident sustained multiple injuries while in care as a result of inadequate supervision." R1 sustained an acute chronic intracranial subdural hematoma, a wrist fracture, and a humerus fracture, which posed an immediate threat to the Health, Safety, and Personal Rights of R1.

Continued...

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 27-AS-20230728105712

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BALANCE ASSISTED LIVING AND MEMORY CARE	FACILITY NUMBER: 392700527
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/25/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/26/2023 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	Basic Services 87464 (f)(1)Basic services shall at a minimum include:..Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidence by:Based on file review and interviews the Licensee did not ensure...	1 2 3 4 5 6 7	Facility staff has reported Basic Service training has been conducted on 10/19/2023 for all staff. Facility agrees to email LPA Martinez training documents by POC Date 10/26/2023 by 5 PM.
	8 9 10 11 12 13 14	R1 was safe from R2. In addition, the Licensee did not ensure there were adequate staff to provide care and supervision to R1 and R2, and did not ensure separation safety measures were put into place for R1 and R2. This posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
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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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20230728105712

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BALANCE ASSISTED LIVING AND MEMORY CARE	FACILITY NUMBER: 392700527
	VISIT DATE: 10/25/2023

NARRATIVE

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A previous Licensing report was issued on 04/23/2023 giving notice of the same violation of California Code of Regulations Section 87464(f)(1). Because you have been cited for repeating the same violation within 12 months, the following civil penalty shall be assessed in the amount of $ 1,000.00 dollars.

Due to R1 sustaining serious bodily injury, the violation warrants civil penalty assessments. At this time, the civil penalty assessments are under review, and a civil penalty determination is pending by the Department. Once civil penalty assessments have been determined, a LPA will return at a future date to assess the civil penalties.

Additionally, please refer to October 25, 2023 LIC 809 Case Management for other violation information.

As a result of this investigation, the Department finds this allegation to be substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted, and a copy of the 9099 report, LIC 9099-D, LIC 421M, and appeal rights were given to the facility.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC9099 (FAS) - (06/04)

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