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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701388
Report Date: 10/07/2025
Date Signed: 10/07/2025 02:19:44 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
06/04/2025 and conducted by Evaluator Kesha Lewis
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250604161942
FACILITY NAME:BALANCE ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
392701388
ADMINISTRATOR:RACHELLE REYESFACILITY TYPE:
740
ADDRESS:1321 S. FAIRMONT AVENUETELEPHONE:
(559) 313-8062
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:136CENSUS: 74DATE:
10/07/2025
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Otero Merylyn TIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility failed to administer medications.
INVESTIGATION FINDINGS:
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On 10/07/2025, Licensing Program Analyst (LPA) Kesha Lewis arirved unannounced to continue the complaint investagation.

R1 moved out of the facility on 6/18/2025, and was amitted on 4/30/2025. R1 required inslin and was unable to administer the medication on their own. LPA reviewed R1's 602, needs and service plan and the medication adminstration recordss from addmission to move out. Based on records reviewed and interview with staff the allegation Facility failed to administer medications is SUBSTANTIATED. R1 was givin an inslin injection by staff. There are also days the facility did not have medication for R1. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

see 9099D page...

Exit interveiw and copy of report and appeal rights given.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 27-AS-20250604161942
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: 392701388
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/08/2025
Section Cited
CCR
87628(a)
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87628 Diabetes
(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement was not met as evidenced by:
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The licensee agreed to do a retraining for all med thechs and send the in-service sign in sheet by POC due date. Kesha.Lewis@dss.ca.gov.
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Based on record review of R1'S file the facility did not ensure to follow the 602 the resident was given an injection on at least one occation.This poses a 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.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC9099 (FAS) - (06/04)
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