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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700527
Report Date: 09/17/2021
Date Signed: 09/17/2021 09:16:10 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 CAREFACILITY NUMBER:
392700527
ADMINISTRATOR:ORELLO, MELISSAFACILITY TYPE:
740
ADDRESS:1321 S FAIRMONT AVENUETELEPHONE:
(209) 334-3436
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:145CENSUS: 68DATE:
09/17/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:MIchelle Fischer, Memory Care DirectorTIME COMPLETED:
09:25 AM
NARRATIVE
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Licensing Program Bruce Jacobs conducted a case management visit at the facility to issue deficiencies relating to an incident reports not submitted to the Department. LPA met with Memory Care Director Michelle Fisher and the purpose of the visit was disclosed. Licensing received information from the Local Health Department that 5 residents had tested positive on 08/11/21. These cases were not reported to Licensing by the facility until 08/18/21. On August 27, 2021, Licensing Program manager Liza King conducted a phone call the Facility. During that phone call, information was obtained that the facility had several residents who had tested positive for an infectious disease. Upon further review, the facility did not submit an incident report as required.

A case management deficiency for failure to report as required is being issued on the following 809D. Appeal rights provided and exit interview conducted.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce JacobsTELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/18/2021
Section Cited

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Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision 87211(a)(2) Occurrences, such as epidemic outbreaks,
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This requirement was not met as evidenced by: Several residents at the facility were tested positive for an infectious disease on 8/11/21. The facility did not report these cases to Licensing until 8/18/21 and therefore failed to submit an incident as required to the department. This poses a potential Health and Safety risk to clients 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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce JacobsTELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2021
LIC809 (FAS) - (06/04)
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