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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700527
Report Date: 03/06/2024
Date Signed: 03/06/2024 04:26:46 PM


Document Has Been Signed on 03/06/2024 04:26 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:BALANCE ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
392700527
ADMINISTRATOR:RODRIGUEZ, JUDYFACILITY TYPE:
740
ADDRESS:1321 S FAIRMONT AVENUETELEPHONE:
(209) 334-3436
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:145CENSUS: 63DATE:
03/06/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:26 PM
MET WITH:Judy Rodriguez and Daisy Aguilar and Stephen Ratlift TIME COMPLETED:
05:00 PM
NARRATIVE
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An unannounced case management visit was conducted by the Licensing Program Analyst (LPA) Avelina Martinez on 03/06/2024 at 9:00 AM. LPA Martinez met with JJudy Rodriguez and Daisy Aguilar and Stephen Ratlift and explain the purpose of the visit.

The purpose of the visit is to follow up on learned deficiencies during compliant investigation 27-AS-20240304084117. During 27-AS-20240304084117 investigation, it was learned resident 1's (R1) primary care physician (PCP) ordered the following on 03/01/2024: Soft and bite sized (level 6 of IDDSI) with regular liquids; 1 to 1 feeder to monitor rate + size; and crush medication to reduce aspiration & chocking. It was learned R1 was not assigned 1 to 1 feeder to monitor rate and size of food. R1 was assigned to a RT group, which consisted of one staff and five other residents. As of today's visit, R1 will be provided a 1 to 1 caregiver for all meals, and facility staff will communicate with R1's PCP in regards to discussing order and request for order to be modified if possible.

Due to this visit, the facility was cited. The citation can be found on the 809-D Page. An exit interview was conducted, and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
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 03/06/2024 04:26 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 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: 03/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/06/2024
Section Cited
HSC
1569.2(c)

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1569.2(c)Care and supervision” means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care.
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As of today, staff agreed to implement 1 to 1 caregiver for all meals. Facility staff reached out PCP on 03/06/2024 to modify 1 to 1 feeder order. Facility staff will email LPA Martinez order changes if any once PCP responds to the request.
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This requirement was not met as evidence by: Based on observation, file review, and interviews, the Licensee did not ensure R1 was provided 1 to 1 feeder at meals. This posed a potential health and safety risk to 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: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
LIC809 (FAS) - (06/04)
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