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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700527
Report Date: 04/04/2024
Date Signed: 04/04/2024 03:54:15 PM


Document Has Been Signed on 04/04/2024 03:54 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: 64DATE:
04/04/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Daisery Agular, Ast AdminTIME COMPLETED:
04:00 PM
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On 04/04/24 at 8:30 AM, Licensing Program Manager (LPM) Liza King arrived at the facility to conduct an unannounced compliant investigations visit as well as to conduct the quarterly visit per the noncompliance conference dated 11/16/2023 and 08/01/23. LPM King met with Daisey Aguilar and explained the purpose of today's visit. LPM was met by LPA Avelina Martinez later in the afternoon. Hospice Residents: 8, Bedridden 2.

Per the Noncompliance conference:
The facility has stated they will do the following to achieve continued and substantial compliance: Increase staffing overall
Hire one additional staff to provide oversight in the memory care unit and assist with preventing resident on resident altercations. New staff will be hired by December 15, 2023
Activity Program Director in Memory Care
Implemented PM shift lead position for Memory Care Unit
Administrator will continue to be present at facility 40 hrs a week.
Conduct Monthly and Weekly training for staff will continue
Staff will receive yearly and additional dementia ongoing training as required.

During todays visit the LPM requested the March 2024 staff schedule to compare to the Nov 2023 schedule provided by the facility which identified 1 chef, 1 chef aide, 4 AM caregivers, 5 PM caregivers, 3 NOC shift caregivers and 2 med techs on AM and PM shift, 1 medtech on NOC shift and one housekeeper for Al and one housekeeper for MC. Upon documentation review and interviews with the Admin, Admin Ast and staff the current staffing schedule for caregivers has increased in MC by one CG on the AM shift and medtechs remains the same as November 2023. Although the Admin reports that the MC area has an Activity Assistant, the licensee has failed to increase overall staffing and there is not an Activity Director nor PM lead position specific in MC which had previously been agreed upon at this time.
SUPERVISOR'S NAME: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


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
VISIT DATE: 04/04/2024
NARRATIVE
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 Additionally, the facility lacks oncall staff for coverage. A review of the March schedule shows several days that staff are not scheduled. A review of the schedule and hours worked per the time clock punches showed that there were only 2 staff scheduled as caregivers on 03/31/24 in the MC area which is insufficient to meet the needs of the residents. Based on interview of staff, several are working 6 days a week. On todays date these staffing concerns were cited on complaint 27-AS-20231220082024.

A review of training records over the past quarter shows that the facility is conducting monthly and ongoing training of all staff.

As stated by the administrator, 100 percent of all residents care plans will be updated and completed by 09/01/23.
Dementia residents will have updated 602’s within 2 weeks by 08/11/23.
During todays visit the LPM reviewed 5 resident files which contained updated physician assessment forms and Needs and Services Plans.

A licensed architect will be engaged for the construction work with a plan to submit building permits by mid August 2023. Facility administrator to provide a copy of permits to CCL once obtained.
To date this has not been received.

The Licensee will continue conducting on-site random visits.
According to staff, the licensees representatives are present in the building more than one day a week. During todays visit a representative introduced themselves as the "management company". A follow up meeting will be scheduled to outline the roles of individuals in the building.

Additional observations today, during a tour of the building today there was no odor and the facilities appeared well kept. LPM observed exercise activities in MC and arts going on in the AL side of the building during the AM hours. LPM observed the laundry room and supply closet unlocked in the MC area and the housekeeping closet in AL unlocked, providing access to toxic chemicals. A fire extinguisher in the MC laundry room is past due for service, last annual maintenance 02/26/2022. The MC delayed egress alarm is sensitive on the maindoor to the area, a call to the company to repair has been made. LPM tested 3 delayed egress doors which were all operational.
SUPERVISOR'S NAME: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 04/04/2024 03:54 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: 04/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/05/2024
Section Cited
CCR
87203

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Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This was not met as evidenced by:
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The Administrator will present proof of correction in the form of photo via email to Avelina.Martinez@dss.ca.gov by tomorrow end of day.
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 a fire extinguisher in MC laundry room was observed to be last serviced in 02/26/2022. This poses an immediate threat to clients in care.
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Type A
04/05/2024
Section Cited
CCR87705(f)(2)

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Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This was not met as evidenced by:
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The Adminitrator will purchase self locking mechanism for the doors and conduct staff training on the topic by end of day tomorrow prrof to be sent to Avelina.Martinez@dss.ca.gov by tomorrow end of day.
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The licensee failed to secure the doors in the memory care area to the laundty room and supply closet which contained cleaning supplies, personal care supllies and related toxins. Although the doors have locks, the locks are not self locking and were observed to be unlocked and accessible. The laundry room door was wide open. This poses an immmediate threat to residents in care.
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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: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 04/04/2024 03:54 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: 04/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/15/2024
Section Cited
CCR
87465(a)(4)

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Incedental and Medical (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by comp shall assist residents with self-administered medications as needed. This was not met as evidenced by:
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The Administrator will create a move in procedure to ensure that the medications are on site at move in. This new process will be reviewed with MedTechs and a copy provided to Avelina by 4/15/2024.
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R4 moved into the facility without all of their prescribed medications for 7 dliance with the following:(4) The licenseeays. This poses a potential risk to clients in care.
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Type B
04/15/2024
Section Cited
CCR87303(i)(1)(a)

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Maintenance and Operation (i) Facilities shall have signal systems which shall meet the following criteria:...

(A) Operate from each resident's living unit. This was not met as evidenced by;
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The Administrator will ensure that pendents are tested monthly by the Maintenance Director and proof of month 1 will be submitted to Avelina Maritiez.
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The call light pendent was nonoperation in R5s room, firmed by a staff member.
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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: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


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
VISIT DATE: 04/04/2024
NARRATIVE
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During a tour of the facility the LPM pushed the response call light in R5s room in the Assisted Living area and waited 11 minutes and 48 sec then the LPM gathered the assistance of a staff person who verified that the call pendent was not operational, appearing to have a dead battery. Interview with the Ast Administrator and care staff confirmed there is not a current process in place for regularly checking the call pendents to ensure that they are operational.

Upon review of MARs during file reviews on todays date, it was determined that R4 moved into the facility in March 2024. Upon move in the client did not have all prescribed medications and had gone without for 7 days. Although the facility made attempts to have the prescriptions filled a plan should be put in place to ensure that medications are onsite for new residents.

As a result of this visit, citations and civil penalties have been assessed and can be found on the 809-D Page as well as the attached 421 forms for additional information. 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: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5