392700527-2-29-2024-27-AS-KHOS-D3PGRN-20240325053434

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700527
Report Date: 02/29/2024
Date Signed: 02/29/2024 02:42:53 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
01/17/2024 and conducted by Evaluator Liza King

COMPLAINT CONTROL NUMBER: 27-AS-20240117144413

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:	07:30 AM
MET WITH:	Judy Rordiguez		TIME COMPLETED:	09:00 AM

ALLEGATION(S):

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9

Facility staff are not properly dispensing medication as prescribed.
Facility is in disrepair.

INVESTIGATION FINDINGS:

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LPM Liza KIng and LPA Avelina Martinez arrived at the facility to follow up on a complaint investigation and were met by Judy Rodriguez, Admin. The purpose of the visit was explained.
During todays visit a review of MARS Dec 2023 and Jan 2024 was conducted. 5 of 5 client files showed missed medication on several days, R1 missed 3 medications more than half of the month. Documentation was inconsistant documenting the reason for the missed medication. For R1, medications missed for over half of the month of Jan, documentation was present for 6 of the days which states that there were no meds. Interview with the Administrator reported that corrective action has been taken against a MedTech due to medications not being ordered timely and residents going without medication.
Additiionally a tour of the MC patio revealed a large trench that had been dug out covered with loose boards, and an awning that has a broken pole and is in disrepair.
As a result of this investigation, the Department finds these 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. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations.
An exit interview was conducted, and a copy of the 9099 report, LIC 9099-D, and appeal rights were given to the facility.

Substantiated

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)

Page: 1 of 1

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
01/17/2024 and conducted by Evaluator Liza King

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240117144413

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:	07:30 AM
MET WITH:	Judy Rodriguez		TIME COMPLETED:	09:00 AM

ALLEGATION(S):

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9

Licensee does not ensure facility is adequately staffed to meet residents
medication needs
Administrator is not present a sufficient number of hours to adequately
manage facility

INVESTIGATION FINDINGS:

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5
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LPM Liza King and LPA Avelina Martinez arrived at the facility today to follow up on a complaint investigation. LPA and LPM met with Judy Rodriquez.

LPM reviewed the facility reports from Jan 17 to current to verify the number of times that CCL staff have been met by the Adminsitrator. Of the five facility visits that have been conducted, 3of the 5 the assigned Admin has been present, the other 2 times CCL staff were met by the Ast Administrator and designee. Interview with 3 staff members during todays visit confirmed that that the Admin is present 5 days a week.
Additionally, according to staff interviewed today, the Directors assist with medications in the absense of a medtech. Directors will be available on other shifts as needed.
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)

Page: 1 of 1

Control Number 27-AS-20240117144413

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: 02/29/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/29/2024 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	(a) 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 was not met as evidenced by:	1 2 3 4 5 6 7	The facilty will fix the awning and block the tranch by end of day today pictures will be sent in to Avelina.NMartinez@dss.ca.gov.
	8 9 10 11 12 13 14	The MC patio is in disrepair, the awning leg is broken, the awning cover is in disrpair. In addition, there is a trench that has been dug and covered with unstable wood this poses an immediate threat to clients in care.	8 9 10 11 12 13 14
Type A 02/29/2024 Section Cited CCR 87211(a)	1 2 3 4 5 6 7	(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This was not met as evidenced by:	1 2 3 4 5 6 7	The Administrator will require MT to review documentation best practices and sign understanding by 03/02. Provide copies via email to Avelina.Martiez@dss.ca.gov.
	8 9 10 11 12 13 14	The facility staff were not documenting the reason for missed medication although MT training is up to date.	8 9 10 11 12 13 14

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: 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

LIC9099 (FAS) - (06/04)

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