392700527-3-6-2024-27-AS-KHOS-D3JNA6-20240320101701

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700527
Report Date: 03/06/2024
Date Signed: 03/06/2024 04:22:16 PM

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
03/04/2024 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240304084117

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: 63	DATE:	03/06/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Judy Rodriguez and Daisy Aguilar and Stephen Ratlift		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff did not follow resident's medication order.

INVESTIGATION FINDINGS:

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On 03-06-2024 at 9:00 AM, Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced facility visit to open a complaint investigation with the above allegation and deliver findings. LPA Martinez met with Judy Rodriguez and Daisy Aguilar and Stephen Ratlift and explained the purpose of today's visit.

Throughout this investigation, LPA Martinez conducted interviews, reviewed medication orders, reviewed Medication Administration Record (MAR), and reviewed resident 1 (R1) facility record. R1's January MAR is missing data entries for Melatonin on January 4 and 6, and (25 thru 31). Melatonin medication was not ordered and not administered. On R1's February 2024 MAR, melatonin 5 MG was not administered from February 1, 2024 to February 29, 2024. MAR documentation reports R1 was out of medication. Additionally, the February MAR is missing a data entry on the fourth. It was also learned R1's primary care physician (PCP) discontinued HCTL on 02/15/2024. R1's PCP also ordered on 02/15/2024 to check R1's blood pressure daily for one week report if SBP </110 or over 150. After one week, conduct blood pressure checks weekly. However, blood pressures checks did not start until 02/23/2024.

Substantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

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
03/04/2024 and conducted by Evaluator Avelina Martinez

COMPLAINT CONTROL NUMBER: 27-AS-20240304084117

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: 63	DATE:	03/06/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Judy Rodriguez and Daisy Aguilar and Stephen Ratlift		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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9

Staff did not follow proper reporting requirements

INVESTIGATION FINDINGS:

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On 03-06-2024 at 9:00 AM, Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced facility visit to open a complaint investigation with the above allegation and deliver findings. LPA Martinez met with Judy Rodriguez and Daisy Aguilar and Stephen Ratlift and explained the purpose of today's visit.

Throughout this investigation, LPA Martinez conducted interviews, reviewed medication orders, reviewed Medication Administration Record (MAR), reviewed resident 1 (R1) facility record, and incident reporting documentation. It was learned facility staff were reporting incidents. Community Care Licensing Department was provided incident reports. Additionally R1's responsible party was called and informed about incidents, however, there was some miscommunicatin between R1's responsible party and facility staff.

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 copy of this report was provided to the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20240304084117

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: 03/06/2024

NARRATIVE

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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.

Due to citation 87465(a)(4) Incidental Medical and Dental Care being a repeat violation, a $1,000.00 civil penalty shall be assessed on 03/06/2024.

An exit interview was conducted, and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 27-AS-20240304084117

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: 03/06/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/11/2024 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465(a)(4) Incidental Medical and Dental Care: A plan for incidental medical and dental care shall be developed by each facility...The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidence by: Based on observation, record review, and	1 2 3 4 5 6 7	Facility agrees to do the following: Med-Tech training on 03/10/2024. Training documentation will be emailed to LPA Martinez on 03/11/2024.
	8 9 10 11 12 13 14	Interviews, the Licensee did not ensure to follow R1's was being administered melatonin 5 MG as ordered. in addition, facility staff did not follow R1's PCP HCTL medication order as written on 02/15/2024. This posed an immediate health and safety risk to R1.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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