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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700527
Report Date: 06/21/2024
Date Signed: 06/21/2024 09:58:35 AM


Document Has Been Signed on 06/21/2024 09:58 AM - 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:BREMER, MERLENEFACILITY TYPE:
740
ADDRESS:1321 S FAIRMONT AVENUETELEPHONE:
(209) 334-3436
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:145CENSUS: 69DATE:
06/21/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Daisy AguilarTIME COMPLETED:
10:00 AM
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On 06/21/2024 at 8:30 AM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility to conduct a case management. LPA Martinez met with Daisy Aguilar and explained the purpose of today’s visit.

The purpose of this visit is to follow up on Incidental and medical and timely medical attention deficiencies for resident 1 (R1).

It was learned R1 was sent to the emergency room on November 10, 2023. R1 was hospitalized due to a femur (thigh bone) fracture and was discharged on November 16, 2023. During this hospitalization, R1 was prescribed oxycodone IR 5 mg tab (Take 1 tablet by mouth every 6 hours as needed for severe pain). Additionally, the hospital’s Oxycodone instructions state, “Your Narcotics are your last resort medication, use mainly at night for comfortable sleep. Remember to taper off your use of narcotics and use the least effective amount”. However, the November 2023 medication administration record (MAR) shows that R1 was being administered Oxycodone routinely. R1’s MAR indicated Oxycodone start date was November 16, 2023. However, the MAR shows R1 was administered Oxycodone from November 1, 2023 thru November 30, 2023. The MAR also indicates R1 was administered Oxycodone in the morning and evening. As a result, the facility was not following the oxycodone order, and did not maintain the MAR.



because you have been cited for repeating the same violation within 12 months (California Code of Regulations Section 87465 (a)(4) Incidental Medical and Dental Care), a civil penalty in the amount of $1,000.00 shall be assessed on 6/21/2024. Please refer to LIC 421IM form for additional information.

Continued...
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024
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 4


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: 06/21/2024
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Furthermore, on November 30, 2023, R1 complained of pain and not being able to feel their legs and requested to be sent out to the Emergency Room (ER) at approximately 7:30 AM. However, per facility note dated November 30, 2023, a facility Med-Tech arrived at R1’s room at 8:00 AM and administered Oxycodone 5 MG pain medication. After R1 was administered the Oxycodone medication, R1 continued to feel pain and requested to be sent to the ER. At this time, the facility called 911, and R1 was sent to the ER. While R1 was in transit to the ER on November 30, 2023, R1 became unresponsive. Emergency Services administered 2 MG of Narcan without improvement. R1 was administered an additional 3 MG of Narcan. After the 3 MG of Narcan, R1 regained consciousness and arrived at the hospital at approximately 9:20 AM.

Moreover, hospital records indicated R1 was diagnosed with acute encephalopathy, moderate dehydration, chronic leg pain, opioid overdose, and acute kidney injury. Additionally, during the November 30, 2023 ER visit, Oxycodone was discontinued. Based on the findings, R1 was not provided timely medical attention, and the course of action taken by the facility resulted in R1 sustaining serious bodily injuries.



An immediate civil penalty shall be assessed on June 21, 2024; since R1 sustained serious bodily injuries due to lack of timely medical attention and lack of care and supervision, which posed an immediate threat to the Health, Safety, and Personal Rights of R1. An immediate $500.00 civil penalty shall be assessed on June 21, 2024. Please refer to LIC 421IM form for additional information.

Due to R1 sustaining serious bodily injury, the violation warrants civil penalty assessments. At this time, the civil penalty assessments are under review, and a civil penalty determination is pending by the Department. Once civil penalty assessments have been determined, an LPA will return at a future date to assess the civil penalties.

An exit interview was conducted, and a copy of this 809 report, 809 D Page, LIC 421IM, 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: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/21/2024 09:58 AM - 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: 06/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/24/2024
Section Cited
CCR
87465(g)

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87465(g) Incidental Medical and Dental Care: The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including...This requirement was not met as evidence by:
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Facility Staff agrees to conduct training for all staff regarding timely medical attention and how to report 911 calls to management by POC Date July 04, 2024 and email training documents to LPA by July 04, 2024 5PM. Facility staff agrees to email LPA training agenda by 06/24/2024 by 5:00 PM.
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Based on records review and interviews, The Licensee did not ensure R1 received timely medical attention, which R1 was not sent to ER when requested by R1 and R1 sustained serious bodily Injury. This posed an immediate health and safety risk to R1.
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Type A
06/24/2024
Section Cited
CCR87465(a)(4)

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87465(a)(4) Incidental Medical and Dental Care: A plan for incidental medical and dental care shall be developed by each facility...The licensee shall assist residents with self-administered medications as needed...This requirement was not met as evidence by
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Facility Staff agrees to conduct training for all staff regarding Medication administration by POC Date July 04, 2024 and email training documents to LPA by July 04, 2024 5PM. Facility staff agrees to email LPA training agenda by 06/24/2024 by 5:00 PM.
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Based on record review and interviews, the Licensee did not ensure R1 staff were following Oxycodone orders. 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: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 06/21/2024 09:58 AM - 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: 06/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/24/2024
Section Cited
CCR
87465(a)(6)

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87465(a)(6) Incidental Medical and Dental Care: A plan for incidental medical and dental care shall be developed by each facility. When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.
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Facility Staff agrees to conduct training for all staff regarding Medication administration and how to maintain MAR by POC Date July 04, 2024 and email training documents to LPA by July 04, 2024 5PM. Facility staff agrees to email LPA training agenda by 06/24/2024 by 5:00 PM.
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This requirement was met by evidence by: based on file review R1's November 2023 MAR was not maintained. This posed a potential 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: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4