392700527-8-16-2024-27-AS-AMAZ-D87MKU-20240816094118

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700527
Report Date: 08/15/2024
Date Signed: 08/16/2024 09:41:23 AM

Document Has Been Signed on 08/16/2024 09:41 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 CARE		FACILITY NUMBER:	392700527
ADMINISTRATOR:	AGUILAR, JONATHAN		FACILITY TYPE:	740
ADDRESS:	1321 S FAIRMONT AVENUE		TELEPHONE:	(209) 334-3436
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY:	145	CENSUS:	DATE:	08/15/2024
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Marlene Bremer, Jonathan Aguilar, Stephen Ratlift		TIME COMPLETED:	02:00 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	Licensing Program Analyst (LPA), Avelina Martinez arrived on 08/16/2024 at 8:45 AM, for an unannounced Case Management visit to follow up on a substantiated allegation of complaint investigation 27-AS-20230728105712. LPA Avelina Martinez met with Marlene Bremer and Jonathan Aguila and explained the purpose of the visit. On October 25, 2023, The Department concluded a complaint investigation which alleged the following, “Resident sustained multiple injuries while in care as a result of inadequate supervision." The Licensee was cited for California Code of Regulations Title 22 (22 CCR) Section 67464 (f)(1) Basic Services; 87411 Personnel Requirements; and 87211 Reporting Requirements. At the time of complaint visit on October 25, 2023, an immediate civil penalty of $500.00 was issued for Section 67464. The Licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code§ 1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section § 15610.67 defines serious bodily injury as "an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by information gathered through interviews and facility files, that the licensee did not ensure R1 received the required care and supervision. Facility staff were aware that a resident (R2) was aggressive towards another resident (R1) but were not present when R2 physically assaulted R1. Per hospital records reviewed, R1 sustained an acute chronic intracranial subdural hematoma, a wrist fracture, and a humerus fracture. Continued...

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

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: 08/15/2024

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Today August 16, 2024, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as a serious bodily injury in the amount of $10,000.00. However, since an immediate civil penalty of $500.00 was previously issued on October 25, 2023, the amount of the civil penalty issued today will be $9,500.00.

A copy of the LIC 421D was given to the facility and originals were signed.

An exit interview was conducted and a copy of the report was issued. Appeal rights provided. Facility representative and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

LIC809 (FAS) - (06/04)

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