392700527-5-29-2024-27-AS-KHOS-D5XMBQ-20240605092819

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700527
Report Date: 05/29/2024
Date Signed: 05/29/2024 02:35:28 PM

Unsubstantiated

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
02/29/2024 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240229092629

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: 67	DATE:	05/29/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Marlene Bremer and Judy Rodriguez		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff left resident in soiled diaper resulting in a UTI.
Staff not maintaining resident's grooming.

INVESTIGATION FINDINGS:

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On 05/29/2024 at 9:40 AM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced to deliver complaint findings. LPA Martinez met with Marlene Bremer and Judy Rodriguez during today’s visit.

Throughout the course of this investigation, LPA Martinez conducted interviews and reviewed facility records, and medical records. Resident's 1 (R1) medical records indicated R1 was diagnosed with sepsis and urinary track infection (UTI). However, the medical records did not state R1's UTI was a result of being left in soiled briefs. Furthermore, there was not sufficient evidence to prove that R1's grooming was not being maintained. During file reviews there was no documentation to state R1 did not receive a shower, or any other grooming tasks. Due to the above noted information, although the allegations may have happened or is valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegatios are 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: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

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 4

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
02/29/2024 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240229092629

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:	05/29/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Marlene Bremer and Judy Rodriguez		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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9

Staff not maintaining resident's hygiene.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 05/29/2024 at 8:40 AM to deliver complaint findings, LPA Martinez met with Marlene Bremer and Judy Rodriguez and explained the purpose of the visit.

Throughout the course of the investigation, LPA Martinez conducted interviews and reviewed resident 1 (R1) facility file. LPA Martinez reviewed R1's Appraisal/Needs and Service Plan. It was determined R1's Appraisal/Needs and Service Plan has not been updated and does not reflect R1's current health status. Please see dated May 29, 2024 809 report for further information. R1's Appraisal Needs and Service Plan states R1' is continent, but uses briefs due to occasional bowel and bladder accidents. Furthermore, R1's LIC 602 Physician Report states, "...Section 15... Capacity for self-care...d. able to care for own toileting needs..NO"

Continued...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 27-AS-20240229092629

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: 05/29/2024

NARRATIVE

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Additionally, R1's Incontinence Care Document indicates R1 was being provided inconsistent incontinence checks. The Incontinence Care Document is missing times and dates, and the document indicates R1 was found with a soiled brief at times. According to R1's Incontinence Care document, R1 was found eight times with a soiled brief.

For example, on March 10, 2024, R1 received the following incontinence check: 6:00 AM R1 was found with dry brief. R1 received a second incontinence check at 10:30 AM, which R1 was found with a wet brief. R1 received a third incontinence check at 4 PM, and per Incontinence Care Document it stated, " brief raggedy wet". On another entry dated March 14, 2024, R1 was found with a wet brief and was showered. Based the obtained documents, R1 was not provided consistent incontinence care, and as a result, R1's hygiene was not maintained.

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

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20240229092629

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: 05/29/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/30/2024 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	Basic Services 87464(f)(1)... Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidence by: Based on file reviews and interviews, The Licensee did not ensure	1 2 3 4 5 6 7	Facility staff agrees to conduct an incontinence file audit and to conduct incontinence reassessments if needed and a in service training on basic services for all staff by POC Date 06/30/2024. LPA Martinez will clear POC by visit.
	8 9 10 11 12 13 14	staff was maintaining R1's hygiene by not provided consistent incontinence care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

LIC9099 (FAS) - (06/04)

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