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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700527
Report Date: 07/03/2024
Date Signed: 07/10/2024 11:07:55 AM


Document Has Been Signed on 07/10/2024 11:07 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:
07/03/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Marlene BremmerTIME COMPLETED:
03:00 PM
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A Non-Compliance Conference (NCC) was conducted today on July 03, 2024 via Microsoft Teams with the Sacramento South Regional Office at 1:30 PM. Present in the meeting were Licensing Program Manager Stephenie Doub, Licensing Program Manager Liza King, and Licensing Program Analyst Avelina Martinez; DHCS representatives: Andrew Chen and Michael Lu, and Mary Tobola; Facility Representatives; Stephen Ratlift, Sharon Wong, and Josh Johnson, Christine Soriano, Shelly Chong, Ombudsman Representative; Kathryn Thomas.

The non-compliance conference process was explained during this meeting to include the Administrative process.

The NCC is being held due to non-compliance. Since the facility was licensed in 2019, the facility has been cited 78 times. The facility has received 40 A Citations and 38 B citations. Additionally since 2019, the facility has received a total of 44 complaints. Since the previous April 18, 2024 NCC, the facility received 6 A citations and 3 B Citations.
  • Deficiencies: Incidental and Medical; Basic Services, Observation of the Resident; Administrator Qualifications; Maintenance and Operations; Care of Persons with Dementia; Reappraisals; Inspection Authority; Personal Rights; Fire Clearance; Care and Supervision; General Food Services; Incontinence Care; Personnel Requirements; First Aid; Hospice Care; Alteration to Existing Building.

Issues discussed during the Non-Compliance Conference were:
  1. Staffing concerns & Staffing Schedules & Position Vacancies & Administrator 40 Hours per week
  2. Facility not able to maintain substantial compliance
  3. Change of Ownership & Facility Census & Call System
  4. Kitchen Food Supply and Dinning Room Capacity and Staggered Meal Sessions.
  5. Medication Errors & Medication Policies & Facility Training Plans
Continued...
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024
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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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: 07/03/2024
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The facility has stated they will do the following to achieve continued and substantial compliance:
  • Medication Training on Relias 10 Hours
  • Medication plan due by July 10, 2024 Please email plan to LPA Martinez.
  • Weekly Medication Audits by Wellness Director
  • Pharmacy Audits-Done Quarterly
  • Daily reviews of Alice care notes
  • Administrator present 40 hours a week. Submit Administrator documentation ( Documents due on July 12, 2024 5:00 PM)
  • Hire Activity Director/Enrichment Director Plan
  • Increase staffing
  • Email weekly work schedules
  • Update LIC 500 Personnel Report and provide form to Community Care Licensing Department (CCLD)
  • Continue conducting on-site random visits
  • Needs and Service/reappraisals Audits-Alice
  • Maintain compliance with ALWP requirements and LVN requirements

In addition, at this meeting the notified Licensee/Administrator was advised future non-compliance regarding the above and other regulatory components will result in additional citations, civil penalties, and further potential administrative action.

Community Care Licensing Department (CCLD) will do the following:

  • Increase Monitoring to quarterly visits.
  • TSP

Completing the Non-Compliance Conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Code if such action is deemed necessary by the Regional Manager.

Per California Code of Regulations (CCRs) - Title 22 no deficiencies are being cited during this visit. An exit interview was conducted with Christine Soriano, and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC809 (FAS) - (06/04)
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