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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700527
Report Date: 03/14/2024
Date Signed: 03/14/2024 02:15:45 PM


Document Has Been Signed on 03/14/2024 02:15 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:
03/14/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Judy Rodriguez & Daisy AguilarTIME COMPLETED:
02:30 PM
NARRATIVE
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An unannounced case management visit was conducted by the Licensing Program Analyst (LPA) Avelina Martinez on 03/14/2024 at 9:00 AM. LPA Martinez met with Judy Rodriguez & Daisy Aguilar and explain the purpose of the visit.

The purpose of the visit is to follow up on learned deficiency during compliant investigation 27-AS-20231218154622. During the investigation, the facility did not have resident's 1 records readily available to inspect, audit, and copy R1's facility records upon demand during normal business hours. On February 29, 2024, LPA Martinez contacted A1 Del Monte Lodi Management Company and requested the following documents: admission agreement, basic rate billing statements, invoices, and outstanding balances. LPA Martinez received R1's admission agreement on March 08, 2024. LPA Martinez received the other requested documents on March 04, 2024.

As a result of this visit, a citation was given. Deficiency 87755 Inspection Authority of the Licensing Agency can be found on the 809-D Page. An exit interview was conducted, and a copy of this 809 report, 809-D page, and appeals rights were given to the facility.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
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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Document Has Been Signed on 03/14/2024 02:15 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: 03/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/01/2024
Section Cited
CCR
87755(c)

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87755(c) Inspection Authority of the Licensing Agency: The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying. This requirement was not met as evidence by:
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Facility staff is currently auditing files and archiving files and reorganizing facility files. Facility staff will complete record filing on 04/01/2024. POC will be cleared by visit.
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Based on observation, file review, and interviews, the Licensee did not ensure to R1's : admission agreement, basic rate billing statements, invoices, and outstanding balances were made available on demand to inspect audit and copy during normal business hours. 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: 03/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2024
LIC809 (FAS) - (06/04)
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