392700527-7-28-2021-27-AS-TWHE-C5BS5F-20210727133416

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700527
Report Date: 07/27/2021
Date Signed: 07/28/2021 07:39:05 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	BALANCE ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	392700527
ADMINISTRATOR:	ORELLO, MELISSA		FACILITY TYPE:	740
ADDRESS:	1321 S FAIRMONT AVENUE		TELEPHONE:	(209) 334-3436
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY:	145	CENSUS: 67	DATE:	07/27/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Melissa Fishcer, Memory Care Director		TIME COMPLETED:	01:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 07/272021 at 8:10am, Licensing Program Analyst (LPA) T. White contacted facility staff, regarding facility risk assessment questions. LPA was unable to get in contact with facility staff. At 9:20am, LPA T. White arrived unannounced to conduct a required 1-year annual inspection. LPA met with Memory Care Director, Michele Fischer and explained the purpose of today’s inspection. Memory Care Director confirmed no staff or clients have experienced symptoms within the last 10 days. LPA was allowed entry into the facility that is licensed to serve a total capacity of 145 non-ambulatory residents which 20 may be on hospice. LPA toured the facility including but not limited to apartments, bathrooms, kitchen, common area, and courtyard. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 73 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ bathrooms was measured at 107.4, 107.8 and 110.5 degrees Fahrenheit. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods. LPA observed smoke detector is interconnected with the fire department. Fire extinguisher was last serviced on August 14, 2020. LPA observed mitigation plan is complete. - LPA observed 7 staff members did not have on a mask upon arrival. - LPA observed unfinished carpet floors located in the memory care unit. - LPA observed 2 residents apartment bathroom faucets did not drain properly. - LPA observed facility does not have a carbon monoxide present during inspection. - CIVIL PENALTY ASSESSED. Report continues on 809C.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BALANCE ASSISTED LIVING AND MEMORY CARE	FACILITY NUMBER: 392700527
	VISIT DATE: 07/27/2021

NARRATIVE

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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 08/03/2021:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted with Memory Care Director. A copy of report and Appeal rights given.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 07/27/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87468.1(a)(2)

Personal Rights of Residents in all Facilities

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in 87468.1(a)(2). LPA observed 7 staff members not wearing masks upon arrival which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/28/2021
	Plan of Correction
1 2 3 4	Director agreed that the facility will conduct in-service training and submit proof to CCLD by POC date.

Type A

Section Cited

HSC

1569.311

Regulations

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and observation, the licensee did not comply with the section cited above in 1569.311. LPA observed no carbon monoxide system in the facility which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/28/2021
	Plan of Correction
1 2 3 4	Director agreed to obtain a carbon monoxide system for the facility and submit proof to CCLD by POC date. CIVIL PENALTY ASSESSED.

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: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

LIC809 (FAS) - (06/04)

Page: 3 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 07/27/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in 87303(a). LPA observed 2 resident bathroom faucets did not drain properly and unfinished carpet floors in memory care unit which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/13/2021
	Plan of Correction
1 2 3 4	Director agreed to repair drain and finish carpet floors. Direct agreed to submit proof to CCL by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

LIC809 (FAS) - (06/04)

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