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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700527
Report Date: 08/20/2024
Date Signed: 08/20/2024 01:00:16 PM


Document Has Been Signed on 08/20/2024 01:00 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:AGUILAR, JONATHANFACILITY TYPE:
740
ADDRESS:1321 S FAIRMONT AVENUETELEPHONE:
(209) 334-3436
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:145CENSUS: 64DATE:
08/20/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH: Jonathan AguilarTIME COMPLETED:
03:30 PM
NARRATIVE
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On 08/20/2024 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 and explained the purpose of today’s visit.

The purpose of this visit is to follow up on learned deficiencies.

It was learned resident 1 (R1) is a registered sex offender, and R2's facility assessment did not include a plan that would address R1's sexual behaviors. Deficiency can be found on the 809D page.

Because you have been cited for repeating the same violation within 12 months (California Code of Regulations Section 87465(h)(2)), a civil penalty in the amount of $1,000.00 shall be assessed 08/20/2024. Please refer to LIC 421IM form for additional information.

Additionally, a Medication error was reported to Community Care Licensing Department (CCLD). On July 27, 2024, a Med-Tech left medication in resident 2's (R2) room. This posed an immediate health and safety risk to R2.

An exit interview was conducted, and a copy of this 809 report, appeals rights, and LIC 421IM were provided to the facility.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024
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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Document Has Been Signed on 08/20/2024 01:00 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: 08/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/20/2024
Section Cited
CCR
87465(h)(2)

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The following requirements shall apply to medications which are centrally stored:Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees... This requirement was not
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Facility conducted a medication training on 08/13/2024 and another training on 08/20/2024. POC cleared at visit
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met as evidence by, based on incident report the, Licensee did ensure facility staff kept medications safe and in a locked place. This posed an immediate health and safety risk to R1.
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Type B
08/20/2024
Section Cited
CCR87457(c)(1)

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Pre-Admission Appraisal-GeneralPrior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs...he appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors
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Facility has initiated pre-admission appraisal review. Also working with families to complete appraisals. Facility implemented this policy on August 1, 2024. POC cleared at visit. Facility staff will email new policy to LPA Martinez by 08/23/2024
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This requirement was not met as evidence by: based on file review and interview the Licensee did not ensure, R1 was assessed for sexual behaviors as they are a registered sex offender. This posed a potential 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: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2