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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700527
Report Date: 04/04/2024
Date Signed: 04/04/2024 03:33:52 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
03/18/2024 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240318113916
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
UNANNOUNCEDTIME BEGAN:
02:03 PM
MET WITH:Daisy Aguilar and Judy RodriguezTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility in disrepair
INVESTIGATION FINDINGS:
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On 04/04/2024 at 2:03 PM, Licensing Program Analyst (LPA) Avelina Martinez and Licensing Program Manager (LPM) Liza King arrived at the facility unannounced to deliver complaint findings. LPA Martinez and LPM King met with Daisy Aguilar and Judy Rodriguez and explained the purpose of today's visit.

Throughout the course of this investigation, LPA Martinez conducted interviews and reviewed facility records. Based on facility records, it was notated that resident 1's (R1) bathroom plumbing was not on in good repair. It was learned on February 07, 2024 an outside plumbing company was contracted to make repairs. However, based on a facility record dated February 15, 2024, R1's bathroom plumbing was not in good repair, and R1 was moved to a different room temporarily. Facility Maintenance employee unplugged shower pipe. Moreover based on interviews, LPA Martinez was informed R1's shower had dirty film stuck on shower floor.

Continued...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
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
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 3
Control Number 27-AS-20240318113916
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: 04/04/2024
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.

An immediate $1000.00 civil penalty shall be assessed on April 04, 2024 because the facility has been cited for repeating the same violation within 12 months (California Code of Regulations Section 87303(a) Maintenance and Operation) Please refer to LIC 421IM form for additional information.

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

SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20240318113916
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: 04/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/04/2024
Section Cited
CCR
87303(a)
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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.
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Facility has purchased plumbing equipment and maintenance employee will continue to monitor plumbing. POC Cleared at time of visit.
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This requirement was not met as evidence by: Based on interviews and file reviews, the Licensee did not ensure R1's bathroom plumbing was in good repair. This posed an immediate 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: 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
LIC9099 (FAS) - (06/04)
Page: 3 of 3