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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 02:11:59 PM


Document Has Been Signed on 08/20/2024 02:11 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 9:30 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.

Resident 1(R1) had multiple falls that entailed Emergency Room (ER) visits. Additionally, the facility did not implement a fall plan. In addition, R1's assessments were not updated after falls. Service plans were dated June 28, 2023 and February 07, 2024.

12/30/2023-Fall with head laceration and staples

01/22/2024-Un-witnessed fall with head incision

03/19/2024-Un-witnessed fall with head injury

As a result, the facility did not complete full reappraisals that included a fall prevention plan. Deficiency can be found on 9099D page.

Because you have been cited for repeating the same violation within 12 months (California Code of Regulations Section 87463 (a)), 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.



Due to R1 sustaining serious bodily injuries and death, the violations warrant civil penalty assessments. At this time, the civil penalty assessments are under review, and civil penalty determinations are 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 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 02:11 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
08/30/2024
Section Cited
CCR
87463(a)

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87463(a) Reappraisals: The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. This requirement was not met as evidence by.
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Completing reappraisals for all resident. conducting reappraisals audit as of 08/01/2024. POC cleared at visit.
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Based on file reviews R1 had multiple falls with hospitalization and a reappraisals were not completed to include a fall prevention plan. This posed an immediate health and safety risk to R1.
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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)
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