392700527-10-21-2021-27-AS-BJAS-C7ZVUJ-20211021164446

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700527
Report Date: 10/21/2021
Date Signed: 10/21/2021 04:44:49 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	BALANCE ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	392700527
ADMINISTRATOR:	ORELLO, MELISSA		FACILITY TYPE:	740
ADDRESS:	1321 S FAIRMONT AVENUE		TELEPHONE:	(209) 334-3436
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY:	145	CENSUS: 67	DATE:	10/21/2021
TYPE OF VISIT:	Office	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Melissa Orello, Administrator		TIME COMPLETED:	02:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 10/21/21 at 2:00 PM, an informal conference was scheduled with the facility and conducted via Teams. Present at the conference were Licensing Program Manager Liza King, Licensing Program Analyst Bruce Jacobs, Managing Partners Josh Johnson and Sharon Wang and Facility Administrator Melissa Orello. The Licensee was informed that this Informal conference is a part of the Administrative Action process and that further citations may result in an elevation to a formal non-compliance conference that could lead to referral to the Department's legal division for possible revocation of license. Issues discussed at the meeting were the facility's management personnel and changes, COVID protocols and recent citations. Licensing received information that current Facility Administrator Melissa Orello will be leaving the facility and new Administrator Daisy Aguilar is to be appointed. Licensing requested a new LIC 200 and LIC 500. The Department is requesting the Administrator to be in the facility for 40 hours per week at this time. Discussed were recent citations given to the facility for failure to follow COVID requirements and the facility's mitigation plan. Upon a Licensing inspection on 07/27/21, 7 staff members were observed not wearing face coverings as required. In addition, the facility was cited on 09/17/21 for failing to report 5 residents had tested positive for the COVID virus and this information was not reported to the Department as required. On 04/23/21 the facility was cited for not allowing Home health to provide services related to the facilities misinterpretation of visitor guidance. Melissa agreed to ensure all COVID and reporting requirements are understood and met. Technical Assistance for Fit testing was provided during the Annual Inspection on 07/27/21, which to date has not been completed. The LPM provided information related to purchasing of the fit testing kit and will email resources for training. Continued Page 1 of 2

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce Jacobs	TELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BALANCE ASSISTED LIVING AND MEMORY CARE	FACILITY NUMBER: 392700527
	VISIT DATE: 10/21/2021

NARRATIVE

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Additional citations discussed that have been issued over the past 12 months include medication related citations and the facility agreed to provide additional training to staff. Receipt of proof of carbon monoxide detectors will be resubmitted to the Regional Office.

Facility agreed to submit documents appointing a new Administrator by COB 10/21/21. Facility also agreed to understand and follow all Provider Information Notices (PIN) instructions and COVID guidance as well as adhering to their Mitigation Plan.

Facility was advised that failure to remain in compliance may result in a non-compliance conference and legal action.

A copy of this Licensing report was emailed to Melissa Orello for signature.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce Jacobs	TELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

LIC809 (FAS) - (06/04)

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