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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701388
Report Date: 06/21/2024
Date Signed: 06/26/2024 03:54:13 PM


Document Has Been Signed on 06/26/2024 03:54 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
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:BALANCE ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
392701388
ADMINISTRATOR:BREMER, MARLENEFACILITY TYPE:
740
ADDRESS:1321 S. FAIRMONT AVENUETELEPHONE:
(559) 313-8062
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:145CENSUS: 69DATE:
06/21/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Shelly Cha, Applicant
Stephen Ratliff, Applicant,
Merlene Bremer, Administrator		TIME COMPLETED:
09:55 AM
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Component II completion: Successful

Facility Type: Resident Care Facility for the Elderly (RCFE)
Application Type: Change in Ownership (CHOW)
Capacity: 145
Census (if any clients in care): 69
COMP II Participants: Shelly Cha, Applicant
Stephen Ratliff, Applicant,
Merlene Bremer, Administrator
Interview Method: Virtual interview (Microsoft Teams)

On June 21, 2024 at 9:00AM, applicants and administrator participated in COMP II. Identification of the applicants and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicants and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22.

During COMP II, CAB analyst confirmed Applicants and Administrator’s understanding of following areas:
1. Facility Operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing Requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General Provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing Readiness

Exit interview conducted with applicants and administrator. Report sent via email and request to return sign copy by end of business day.
SUPERVISOR'S NAME: Darla NeeleyTELEPHONE: (916) 651-7817
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: 916-657-2469
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2024
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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