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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700527
Report Date: 07/31/2024
Date Signed: 07/31/2024 03:31:01 PM


Document Has Been Signed on 07/31/2024 03:31 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:BREMER, MERLENEFACILITY TYPE:
740
ADDRESS:1321 S FAIRMONT AVENUETELEPHONE:
(209) 334-3436
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:145CENSUS: 66DATE:
07/31/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jonathan Aguilar, Marlene Bremer, and Stephen Ratlift TIME COMPLETED:
03:45 PM
NARRATIVE
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On 07/31/2024 at 9:00 AM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility to conduct a case management. LPA Martinez met with Jonathan Aguilar, Marlene Bremer, and Stephen Ratlift and explained the purpose of today’s visit.

The purpose of this visit is to follow up on wrongful death deficiency for resident 1 (R1).

Resident 1 (R1) had a history of a femur fracture. R1 sustained a femur fracture in December of 2022. R1 received medical attention and was admitted into a skilled nursing facility (SNF). R1 was discharged from the SNF on August 11, 2023, to A1 Del Monte Lodi/Balance Assisted Living and Memory Care Facility. A facility file review for R1 was completed. The facility did not conduct a needs and service plan and did not conduct an assessment after being admitted into the facility. R1 did have a LIC 602 Physician’s report, LIC 603 Pre-Placement Appraisal, and LIC 7172 Functional Capability Assessment.



The facility did not conduct reappraisals and did not note R1’s significant changes to keep the appraisal accurate. As a result, R1 was not provided the care that was required. On November 10, 2023, R1 was sent to the Emergency Room (ER). The chief complaints at the hospital were leg pain and increased weakness. Per medical notes, it was reported R1 was experiencing leg pain for three months. On November 10, 2023, R1’s leg pain became debilitating and could no longer walk. It was also noted R1 reported sustaining two falls three months prior to November 10, 2023. However, the facility did not document any falls, and Community Care Licensing Department (CCLD) did not receive any fall incident reports.

Based on the November 10, 2023, ER visit, R1 was diagnosed with a hip fracture. Due to the medical finding, R1 was transported to another hospital on November 10, 2023, to receive medical attention
R1 was treated for a left hip fracture and had an operative procedures. R1 was discharged to A1 Del Monte Lodi/Balance Assisted Living and Memory Care Facility on November 16, 2023. Upon R1’s arrival, the facility did not conduct a reassessment. In addition, the facility did not conduct a fall risk assessment. Continued...
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2024
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: 07/31/2024
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As a result, the facility did not implement a plan that would note R1' significant changes. In addition to, implementing a plan that would observe new physical and health changes and include fall prevention precautions. It was also learned, R1 was sent to the ER on November 30, 2023, for pain and not being able to feel their legs. R1 returned to the facility on November 30, 2023, and was not reassessed. On December 01, 2023, R1 sustained an un-witnessed fall, and it is unknown how long R1 was on the ground. R1 sustained abrasions to left knee and elbow. R1 was sent to the ER and was admitted into the hospital.

Due to A1 Del Monte Lodi/Balance Assisted Living and Memory Care Facility lack of: fall precaution plan, observation of R1, and care and supervision, R1 sustained serious bodily injuries, which resulted in death. Contributed factors to R1’s death as noted on the Death Certificate include, mechanical falls and left side hip fracture. Due to R1 sustaining serious bodily injuries and death, 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 immediate civil penalty shall be assessed on July 31, 2024; based on the fact the facility did not provide basic care services to R1, which posed an immediate threat to the Health, Safety, and Personal Rights of R1. Moreover, because you have been cited for repeating the same violation within 12 months (California Code of Regulations Section 87464(f)(1) Basic Services), a civil penalty in the amount of $1,000.00 shall be assessed on 07/31/2024. Please refer to LIC 421IM form for additional information.

An exit interview was conducted, and a copy of this 809 report, 809-D page, appeals rights, and LIC 421IM was provided to the facility.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/31/2024 03:31 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: 07/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/14/2024
Section Cited
CCR
87464(f)(1)

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87464(f)(1) Basic Services: 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).
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Facility Staff agrees to complete assessment audit on fall risk residents by POC Date 08/14/2024. Facility agrees to email assessment audit plan by 08/01/2024
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This requirement was not met as evidence by: based on interviews and interviews and file reviews, the Licensee did not ensure facility staff were meeting R1' s needs which resulted in death. This posed an immediate and health risk to R1
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Type A
08/07/2024
Section Cited
CCR87211(a)(1)

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Reporting Requirements 87211(a)(1): each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:A written report shall be submitted to the licensing agency and to the person responsible
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Facility staff agrees to conduct a reporting in-service training by August 07, 2024. Email training materials by 5:00 PM to LPA Martinez
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for the resident within sevendays of the occurrence.. This requirement was not met as evidence by: Based on the file reviews and interviews, the Licensee did not ensure facility reported incidents to the responsible party and CCLD. 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: 07/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2024
LIC809 (FAS) - (06/04)
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