392700527-7-31-2024-27-AS-KHOS-D83KS8-20240812080906

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700527
Report Date: 07/31/2024
Date Signed: 07/31/2024 04:25:41 PM

Substantiated

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
07/08/2024 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240708164104

FACILITY NAME:	BALANCE ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	392700527
ADMINISTRATOR:	BREMER, MERLENE		FACILITY TYPE:	740
ADDRESS:	1321 S FAIRMONT AVENUE		TELEPHONE:	(209) 334-3436
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY:	145	CENSUS: 66	DATE:	07/31/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jonathan Aguilar, Marlene Bremer, and Stephen Ratlift		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility staff are not meeting resident's needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 07/31/2024 at 9:00 AM to deliver complaint findings, LPA Martinez met with Jonathan Aguilar, Marlene Bremer, and Stephen Ratlift and explained the purpose of today’s visit.

Throughout the course of the investigation, LPA Martinez conducted interviews, toured the facility, reviewed facility records. Community Care Licensing Department (CCLD) requested the following documents:
• Any LIC 624’s related to falls from Jan 2024 through current date
• LIC 602 (2023 and 2024)
• Preadmission appraisal and any and all reappraisals from Jan 2024 through the current date
• Emergency contact info face sheet
• Copy of MAR for Jan 2024 to current
• Synopsis of any med changes Jan 2024 to current
• Any discharge summaries from Jan 2024 to current Continued...

Substantiated

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: 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.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 27-AS-20240708164104

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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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Upon review of documentation provided by the facility, it was learned that R1 has been to the emergency room (ER) six times since February 2024 per the discharge summaries provided, two of which were reported to CCLD (04/10/24 and 07/02/24) (two additional hospitalizations are referenced on incident reports (IR) provided to CCLD on 06/07/24 and 06/08/24, that did not accompany a discharge summary) Six of the eight times were related to falls (04/10/24,06/07/24, 06/08/24, 07/02/24, 07/12/24 and 07/16/24).

Additionally, it was learned that one emergency room visit was “due to another resident attacking R1 resulting in swelling black eye”. This incident was not reported to CCLD. The facility provided three Needs and Service (N&S) Plans (03/01/24, 04/23/24, 06/01/24) one of three was signed by the responsible party with a fax stamp of date, none were signed or dated by the facility representative. Of the three N&S plans provided, the fall precaution documented is to “make sure R1 has their wheelchair” (06/10/24), no other fall precautions were implemented. Additionally, the N&S plan was not updated when there was a change in condition such as the resident sustaining multiple falls, a change in diet (03/01/2024) and admission onto hospice. A resident appraisal was provided dated 07/17/24 which documents the soft diet, monitor at meal times and need for 1:1 care related to mobility, no N&S plan was provided which reflected this. As a result, of not addressing R1's health condition changes, resident on resident altercation, and falls, R1 did not receive the required care they needed.

An immediate civil penalty shall be assessed on July 31, 2024; based on the fact the facility did not provide care and supervision to R1 (87705 (c)(5)(A) Care of Persons with Dementia), which posed an immediate threat to the Health, Safety, and Personal Rights of R1. An immediate health and safety civil penalty in the amount of $ 500.00 shall be assessed on 07/31/2024. Please refer to LIC 421IM form for additional information.

Due to R1 sustaining serious bodily injuries from falls and altercations, 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 exit interview was conducted, and a copy of this 9099 report, 9099-D page, appeals rights, and LIC 421IM were provided to the facility.

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

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
07/08/2024 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240708164104

FACILITY NAME:	BALANCE ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	392700527
ADMINISTRATOR:	BREMER, MERLENE		FACILITY TYPE:	740
ADDRESS:	1321 S FAIRMONT AVENUE		TELEPHONE:	(209) 334-3436
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY:	145	CENSUS: 66	DATE:	07/31/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jonathan Aguilar, Marlene Bremer, and Stephen Ratlift		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility does not have an adequate food supply.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 07/31/2024 at 9:00 AM to deliver complaint findings, LPA Martinez met with Jonathan Aguilar, Marlene Bremer, and Stephen Ratlift and explained the purpose of the visit.

Throughout the investigation, LPA Martinez conducted interviews, conducted food inspections, and reviewed facility documents. It was determined the facility has an adequate food supply. During food inspections and food supply observations, LPA Martinez observed a sufficient amount food.

Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility.

Unsubstantiated

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: 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.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20240708164104

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 08/22/2024 Section Cited CCR 87705(c)(5)(A)	1 2 3 4 5 6 7	87705 (c)(5)(A) Care of Persons with Dementia: When any medical assessment, appraisal, or observation indicates that the resident’s dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident. This requirement was not met	1 2 3 4 5 6 7	Facility Staff agrees to conduct in-service training on observation of dementia residents, appraisals, and caring dementia residents by POC Date 08/22/2024. Staff agrees to email training materials by 08/22/24 5:00 PM. Training plan will be emailed to LPA Martinez by 08/01/24 5:00 PM,
	8 9 10 11 12 13 14	as evidence by: based on file review, interviews, and observations, the Licensee did not ensure R1' was receiving the required care they needed. This posed an immediate health and safety risk to R1.	8 9 10 11 12 13 14
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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 King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 4 of 4