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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 03:54:53 PM


Document Has Been Signed on 07/31/2024 03:54 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:
04:30 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 the visit is to follow up on deficiencies regarding the following: reporting requirements, personal rights, and reappraisals.

Reporting Requirements: It was learned resident 1 (R1) sustained multiple falls, which not all falls were reported to Community Care Licensing Department (CCLD). R1 sustained injuries due to a resident on resident altercation. This resident on resident abuse altercation incident was not reported to CCLD.



Because you have been cited for repeating the same violation within 12 months California Code of Regulations Section 87211(a) Reporting Requirements, 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.

Reappraisals: R1 had significant health condition changes and reappraisal were not updated to reflect the changes.

Because you have been cited for repeating the same violation within 12 months California Code of Regulations Section 87463(a) Reappraisals, 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.


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)
Page: 1 of 4


Document Has Been Signed on 07/31/2024 03:54 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
08/07/2024
Section Cited
CCR
87211(a)(1)(d)

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87211(a)(1)(d) Reporting Requirements: 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...
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Facility staff agrees to conduct a reporting in-service training by August 07, 2024. trainining plan will be emailed to LPA by 08/01/2024 5:00 PM. Email training materials by 5:00 on August 07, 2024 PM to LPA Martinez.
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This requirement was not met as evidence by: based on file reviewed interviews, the Licensee did not ensure to submit R1 falls/health changes/ resident on resident incident reports to CCLD. This posed an immediate health and safety risk to R1.
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Type A
08/07/2024
Section Cited
CCR87468.1(a)(2)

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87468.1(a)(2)Personal Rights of Residents in All Facilities:Residents in all residential care facilities for the elderly shall have all of the following personal rights:o be accorded safe, healthful and comfortable accommodations...This requirement was not met as evidence by:
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Facility staff agrees to conduct personal rights of residents in-service training by August 07, 2024. trainining plan will be emailed to LPA by 08/01/2024 5:00 PM. Email training materials by 5:00 on August 07, 2024 PM to LPA Martinez.
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based on interviews and file reviews, the Licensee did not ensure R1 was provide a safe healthful and comfortable accommodations, which led to R1 sustaining injuries from a resident on resident altercation. 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: 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)
Page: 2 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: 07/31/2024
NARRATIVE
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Personal Rights of Residents in All Facilities: It was learned R1 was not accorded a safe healthful accommodation and environment, which led to R1 sustaining injuries from a resident on resident altercation.

Incidental and Medical: During today's visit, LPA observed a medication pill on the floor. LPA Martinez informed staff 1, and staff 1 removed the medication pill from the floor. (Pill located at front resident lobby area).

The deficiencies were observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. An exit interview was conducted, and a copy of this report 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)
Page: 4 of 4
Document Has Been Signed on 07/31/2024 03:54 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
87463(a)

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87463(a) Reappraisals: The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate.
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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 to LPA Martinez by 5:00 PM
Type A
08/07/2024
Section Cited
CCR
87465(h)(2)

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The following requirements shall apply to medications which are centrally stored:entrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees...This requirment was not met as evidence by: based on observation LPA
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Facility staff agrees to conduct incidental and medical in-service training by August 07, 2024. Trainining plan will be emailed to LPA by 08/01/2024 5:00 PM. Email training materials by 5:00 on August 07, 2024 PM to LPA Martinez.
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Martinez found a medication pill on the floor at resident lobby. This posed an immediate 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: 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)
Page: 3 of 4