392701388-8-20-2024-27-AS-AMAZ-D8C32E-20240820175148

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392701388
Report Date: 08/20/2024
Date Signed: 08/20/2024 05:51:57 PM

Document Has Been Signed on 08/20/2024 05:51 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 CARE		FACILITY NUMBER:	392701388
ADMINISTRATOR:	BREMER, MARLENE		FACILITY TYPE:	740
ADDRESS:	1321 S. FAIRMONT AVENUE		TELEPHONE:	(559) 313-8062
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY:	145	CENSUS: 64	DATE:	08/20/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:06 PM
MET WITH:	Jonathan Aguilar		TIME COMPLETED:	06:30 PM

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Licensing Program Analyst (LPA) Avelina Martinez and Licensing Program Manager (LPM) Liza King arrived announced to conducted a Pre-Licensing Inspection of the facility to ensure compliance with Title 22 regulations. LPA and LPM met with Jonathan Aguilar who assisted in today’s inspection.

Facility has a fire clearance for 115 non-ambulatory residents and 30 bedridden residents. Jonathan Aguilar, will be the Administrator of this facility and holds a current administrator’s certificate.

LPA, LPM, Jonathan Aguilar, Daisy Aguilar, and Serena Villanueva inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, and kitchen.

The following Items were not in good repair:

exposed wires throughout the facility
signal system not set up
Ombudsman poster is not the required size
Ring Camera needs to be included in the plan operation (audio needs to be shut off)
Facility equipment not in use should be removed
Memory Care Egress Door Hinge needs to be replace. (door not self latching/closing)
Fence boards at back of building need to be repaired (Memory Care/Assisted Living Side)
Swamp Cooler located in facility kitchen is not in good repair (not cooling efficiently)
Memory Care unit alarms are not in good repair
Screens missing throughout the facility.
Smoking area in assisted living area need to be cleaned and drains need caps
Facility common areas are locked during business hours (open door policy needs to be put in place) Continued...

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (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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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: 392701388
	VISIT DATE: 08/20/2024

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13. bathroom furnishings need to be repaired both in Memory Care and Assisted Living.
14. Assisted Living Hallway floor transition board needs to be replaced. (not wheelchair accessible)
15. Dry rot of building boards in Memory care need to be replaced.
16. Carpet throughout the facility needs to be cleaned.
17. Memory Care sliding glass door needs to be replaced or repaired.
18. Kitchen refrigerator needs to be clean. (Frost bite build up)
19. Pest control services are required throughout the facility.
20. Repair light fixture in emergency food storage room.
21. Female resident room located in assisted living unit has a wall behind door (copy of the permit shall be emailed to CCLD by 08/20/2024)
22. Plan of Operation update: egress, Dinning program, dementia plan, security Video, smoking area, food supply policy, meal tray service policy, and dinning room table settings and space (dinning tables accommodate 32 residents) .
23. Facility Sketch needs to be updated to show bedridden room, egress doors, staff bathrooms, and hospice rooms.
24. Rails in Memory care need to be added.
25. Trash cans need lids.
26. Memory Care unit needs a common area for resident use.

The applicant has not passed the pre-licensing component of the application process. An LPA will return to facility to complete pre-licensing visit once above items have been corrected.

an exit Interview was conducted, and a copy of this report was 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: 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

LIC809 (FAS) - (06/04)

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