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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700527
Report Date: 04/29/2024
Date Signed: 04/29/2024 01:56:38 PM


Document Has Been Signed on 04/29/2024 01:56 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: 63DATE:
04/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Judy Rodriguez and Stephen Ratlift and Christine SorianoTIME COMPLETED:
02:00 PM
NARRATIVE
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On 04/29/2024 Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection. LPA Martinez met with Judy Rodriguez and Stephen Ratlift and Christine Soriano and explained the purpose of the visit.

LPA Martinez reviewed facility files to ensure compliance with Title 22 regulations.

Administrator holds current certificate. The facility is licensed for 145 non-ambulatory residents, which 5 may be bedridden. The facility has a hospice waiver for 20 and has delayed egress located at the Memory Care Unit. There are currently 63 residents who reside at this facility.

During today's inspection, ten resident files and ten staff files were reviewed. Five out of ten staff files were missing some of the following documents: first aid, health screening reports, and TB results. Ten resident files were complete. The facility has a infection control plan and a natural disaster plan.

This annual inspection will require a continuation visit. LPA Martinez will return at a later date to complete the annual inspection.

An exit interview was conducted, and a copy of this 809 report, 809-D page, and appeals rights were provided to the facility.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2024
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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Document Has Been Signed on 04/29/2024 01:56 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: 04/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2024
Section Cited
CCR
87411(c)(1)

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87411(c)(1) Personnel Requirements - General. All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69...Staff providing care shall
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Facility staff agrees to conduct a first aid file audit and conduct training for all staff that have not completed first aid training by an outside training agency by POC Date 05/15/2024. Staff agrees to email first aid training document to LPA Martinez by POC date 05/15/24
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receive appropriate training in first aid from persons qualified...This requirement was not met as evidence by: Based on file review the Licensee did not ensure 4 care staff completed first aid training. This posed a potential health and safety risk to residents in care.
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Type B
05/15/2024
Section Cited
CCR87411(f)

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87411(f) Personnel Requirements - General. All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening...This requirement was not met as
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Facility staff agrees to conduct a health screening file audit and ensure all staff have a completed health screen report LIC 503 by POC Date 05/15/2024. Staff agrees to email health screening audit documents to LPA Martinez by POC date 05/15/24
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evidence by: based on file review, the Licensee did not ensure 4 staff completed a health screening report LIC 503. This posed a potential health and safety risk 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: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2024
LIC809 (FAS) - (06/04)
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