392700527-2-29-2024-27-AS-KHOS-D34J3E-20240306054126

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700527
Report Date: 02/29/2024
Date Signed: 02/29/2024 01:04:12 PM

Unsubstantiated

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
01/18/2024 and conducted by Evaluator Liza King

COMPLAINT CONTROL NUMBER: 27-AS-20240118104214

FACILITY NAME:	BALANCE ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	392700527
ADMINISTRATOR:	RODRIGUEZ, JUDY		FACILITY TYPE:	740
ADDRESS:	1321 S FAIRMONT AVENUE		TELEPHONE:	(209) 334-3436
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY:	145	CENSUS:	DATE:	02/29/2024
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Judy Rodiguez		TIME COMPLETED:	12:50 PM

ALLEGATION(S):

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Staff did not ensure adequate supervision resulting in residents eloping from facility.

INVESTIGATION FINDINGS:

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LPM Liza King and LPA Avelina Martinez arrived at the facility today to follow up on this complaint invesitgation. Based on the information provided there was insufficient information of whom had eloped from the facility that the RP observed. The LPM requested police records to identify if any missing persons reports were made from the facility on or around the date of the complaint with no avail. LPM reviewed Incident Reports received by the facility on or around the date of the complaint. The facility had not submitted any AWOL incident reports.

Due to the above noted information, 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, and therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Krystall Moore	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

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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