392700527-6-21-2024-27-AS-LKIG-D7P2JM-20240730172635

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700527
Report Date: 06/21/2024
Date Signed: 06/21/2024 09:46:50 AM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/31/2024 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240131110429

FACILITY NAME:	BALANCE ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	392700527
ADMINISTRATOR:	RODRIGUEZ, JUDY		FACILITY TYPE:	740
ADDRESS:	1321 S FAIRMONT AVENUE		TELEPHONE:	(209) 334-3436
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY:	145	CENSUS: 69	DATE:	06/21/2024
		UNANNOUNCED	TIME BEGAN:	08:25 AM
MET WITH:	Daisy Aguilar		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Questionable Death

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 06/21/2024 at 8:25 AM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced to deliver complaint findings. LPA Martinez met with Daisy Aguliar and explained the purpose of today’s visit.

Throughout the course of this investigation, The Department conducted interviews, reviewed facility records, and reviewed medical records. It was learned R1 did not pass away due to a drug overdose. Based on R1’s death certificate, R1’s cause of death was the following: respiratory failure (onset days), congestive heart failure/volume overload (onset days), Sepsis (onset days), infected left hip (onset weeks). This agency has investigated the complaint alleging “questionable death”. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted, and a copy of this report was provided to the facility.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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