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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701388
Report Date: 08/28/2025
Date Signed: 08/28/2025 04:13:50 PM

Document Has Been Signed on 08/28/2025 04:13 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:
392701388
ADMINISTRATOR/
DIRECTOR:		RACHELLE REYESFACILITY TYPE:
740
ADDRESS:1321 S. FAIRMONT AVENUETELEPHONE:
(559) 313-8062
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 136CENSUS: 76DATE:
08/28/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Marilyn Otero TIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michael Bilger and Licensing Program Manager (LPM) Liza King arrived unannounced to conduct a follow up visit regarding a complaint investigation and follow up on incident reports receieved. LPM and LPA met with Marilyn Oterl and explained the purpose of the visit.
LPM conducted a tour of the facility and observed:
Memory Care area – resident restrooms do not contain soap for handwashing. Interview with the designee reported that soap is not allowed in memory care area, technical guidance was provided by LPM on non toxic soap or soap dispensers that should be in each restroom area. Additionally interview with a family member reported that residents are not allowed electric shavers, numerous residents observed unshaven. Guidance provided that resdients are allowed access to electrical razors. Tour of memory care rooms revealed sliders and windows inoperable in the common area and in one room toured. Additionally more than 5 rooms observed to have toxins accessible. Breakfast service was done at 8:30 except for those eating in their rooms and included hot cereal, eggs bacon, sausage and coffee cake. LPM also observed juices, oranges and banannas being served. Residents were seated in the lobby area, activites were to begin at 9 am which was not observed to occur. Guidance was provided on allowing resdients to remain in the dining area which was locked and activities such as morning news, talk shows or music to be on while others congregate in the lobby area reducing the number of residents in that area. Additionally it is acceptable to have a TV or music area in the lobby as long as the fire exit is accessible and clear from traffic in case of emergency. Engageing residents throughout the memory care area should allow for this and engage the residents. An additional tour was conducted after lunch, no activites were being offered and the dining room was locked again. Additional guidance provided. First hall in MC is malodorous. Temperature comfortable although portable units located throughout building. Linen available in washroom.

Cont
NAME OF LICENSING PROGRAM MANAGER: Krystall Moore
NAME OF LICENSING PROGRAM ANALYST: Liza King
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 11
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 11
Document Has Been Signed on 08/28/2025 04:13 PM - It Cannot Be Edited


Created By: Liza King On 08/21/2025 at 10:12 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 08/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/29/2025
Section Cited
CCR
87463(b)

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(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. The licensee failed to do this asevidenced by
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The licensee agrees to audit the apprasiasals and update 5 per week. Monthly an audit reconcilation will be sent to to Kesha.Lewis@dss.ca.gov.
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Multiple residents had generalized ststements incl R2 had 5 unwitnessed falls, no interventions were documented on the CP to address the fall risk, R6 had 4 falls the generalized intervention remains after the update “staff will provide oversight and complete interventions to help reduce residents fall risk”. Interventions are not documented and the CP is not updated to address the fall risk. Additioanlly the 080325 reappraisal is blank. R11 had 6 unwitnessed falls no specific interventions are noted just that they will be implemented, statement is the same across this resdients CPs. This poses an immediate risk to resdients in care
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Type A
09/03/2025
Section Cited
CCR87609(b)(2)

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The licensee provides the supporting care and supervision needed to meet the needs of the resident receiving home health care.This was not met as evidenced by
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Licenssee will observe the resdients and collaborate with home health. Updates will be made to the home health progress notes and sign in sheet. A copy will be provided to to Kesha.Lewis@dss.ca.gov.
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R3 - . The CPs although documented as updated did not document the change in condition including new or worsening wounds, facility oversite of care being provided, observation of wounds and pain management for this resident. Additionally the 05/28/25 CP did not document any showering or toileting assistance. R4 was hospitalized on 2 separate occasions in the past 6months. A review of medical records was conducted, CPs have been updated. Interventions are generalized and are not personalized ie there is a third party vendor in place to assist with management of skin care/wounds, however no description of the wound(s) locations, status, treatment or measurable goals are noted on the resident’s CP, nor any direction to staff such as observe for changes. This poses an immediate risk to resdients 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.
Krystall Moore
NAME OF LICENSING PROGRAM MANAGER:
Liza King
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2025


LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 08/28/2025 04:13 PM - It Cannot Be Edited


Created By: Liza King On 08/21/2025 at 10:20 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 08/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/03/2025
Section Cited
CCR
87465(a)(4)

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(4) The licensee shall assist residents with self-administered medications as needed. This was not as evidenced by:
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Licensee agrees to audit medications to determine which residents are currently out of medications then submit LIC624 and plan for each to Kesha.Lewis@dss.ca.gov.
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a review of R7s MARS for the months of June 2025 thru Aug 2025 was conducted and revealed on 6/26/25 am meds were not documented as being provided. Additionally an inhaler was not provided during the month of June, July or August. medications were refused on the following dates, 07/11, 13, 16, 17, 17, 20, 25.No IR received for refusal or missed medications. This poses an immediate risk to clients in care.
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Type A
09/03/2025
Section Cited
CCR87463(c)1-3

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(c) If the licensee observes or is made aware of behavioral expression, as defined in Section 87101, that has caused or may cause harm to the resident or others, the licensee shall document all of the following in the resident’s reappraisal:(1) A description of the behavioral expression.

(2) If known, identification of events occurring just prior to the behavioral expression including, but not limited to, interactions with other residents or staff, sudden or recent changes in the physical environment, signs of possible new physical illness or injury (such as fever, cough, urinary urgency, or limping), overstimulation (such as from noise or visitors), or physical sensations a resident may not be able to express verbally that may include, but are not limited to, fatigue, heat, cold, pain, hunger, thirst, boredom, fear, wanting to walk, or need for toileting.

(3) Interventions to be implemented to minimize the risks to the health and safety of the resident or others associated with the resident's behavioral expression. The licensee shall use the least restrictive intervention to manage the behavioral expression based on the individual needs of the resident.The facility failed to implement this as evidenced by:
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Licnesee will update the care plans of residents in Memory Care and submit examples to Kesha.Lewis@dss.ca.gov.
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R7 was sent to the ER due to agitation a change of medication was noted and 2 subsequent falls were reported. A review of the CP documents updates were made, however it is unclear what changes were made. Triggers are not identified and Interventions do not include behavior modifications or monitoring for side effects of new medications which may have attributed to falls. Additionally prn medications were available and not used prior to sending the reisdent to the ER for agitation two times in one day.
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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.
Krystall Moore
NAME OF LICENSING PROGRAM MANAGER:
Liza King
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2025


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: 08/28/2025
NARRATIVE
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Assisted Living was toured residents appeared content. Resident rooms were inspected for clean linen, cleanlieness and odor as well as operable windows and sliders. During the inspection two rooms were observed to be dirty, inc. used briefs in garbage, excess garbage and clutter and dirty floors. Two residents reported that housekeeping is provided one time a week. Common areas were observed to be clean. House Keeping room was open and assessable to clients. Common door on hall to the exterior was locked from inside and not accessible. This should remain unlocked during busineess hours. One room was toured with an excess of 10 O2 canisters unsecured documentation was reviewed, on two occasions the facility has reached out to the company to provide holders, no other means of securing for safety have been made.
LPM interviewed the chef regarding meal substitutions. A request was made to review consultation notes from the facilities registered dietician. The chef confirmed that they have not met the dietician and reports were not available for review. Vegartariens are provided substitutions but there is no record of what is being served and if it meets requirements.

A review of incident reports occurred for 11 residents. Documentation was requested via email and included hospital discharge (DC) documentation, Medication administration records (MARS) and care plans(CP) for review prior to todays visit.

R1 had 2 unwitnessed falls between the months of 05/2025 and 07/2025, one of which resulted in a fracture. The hospital documentation was reviewed as well as the CP during this time period. Although the CPs were updated the change in condition is not noted and pain management is not addressed. Additional follow up is needed and R1s resident records are being requested today to include the following: Admissions Agreement, Emergency Contact information, current and prior LIC602, Preadmissions appraisal, any reappraisal for the period of April 2025 to current, service notes for the period of April 2025 to current, any hospital discharge documents for the period of April 2025 to current, and MARs for the period of April 2025 to current, any documentation of communications to the responsible party or MD regarding reportable conditions.

R2 had 5 unwitnessed falls in a period of less than 3 months. A review of medical records was conducted, CPs are documented as being updated, however there is no update to the problems or interventions thus it does not appear that interventions were not put in place to address residents’ risk of falls. No fall risk is identified on the CP. Additionally, interventions are generalized and are not personalized ie staff to understand resident’s activity preference.


cont.
NAME OF LICENSING PROGRAM MANAGER: Krystall Moore
NAME OF LICENSING PROGRAM ANALYST: Liza King
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 08/28/2025 04:13 PM - It Cannot Be Edited


Created By: Liza King On 08/28/2025 at 11:56 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 08/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/28/2025
Section Cited
CCR
87309

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(c) Except as specified in subsection (d), the licensee shall implement reasonable interventions in order to ensure that nutritional supplements, vitamins, alcohol, cigarettes and other potentially toxic substances, such as certain plants, gardening supplies, and auto supplies, are stored so as not to pose a hazard to residents. This was not met as evidenced by
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Licensee removed all toxins and locked the door to housekeeping during todays inspection. NO POC necessary.
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A tour revealed a housekeeping closet open and accessible in the Assisted Living Area of the building with chemicals present. Additionally the Memory Care resident rooms had shampoo conditioner periwash toothpaste and deoderant accessible. This poses an immediate threat to resdients in care
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Type A
08/29/2025
Section Cited
CCR87613(b)(3)(E)

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(E) Oxygen tanks that are not portable shall be secured in a stand or to the wall. This was not met as evidenced by
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Licensee has contacted the complany to safety store the oxygen if there is no response then a storage room will be identified, used and signage posted. If this is the practice an updtaed facility sketch willbe submitted.
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LPM observed one room with 9 oxygen canisters not secured. This poses an immediate threat 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.
Krystall Moore
NAME OF LICENSING PROGRAM MANAGER:
Liza King
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2025


LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 08/28/2025 04:13 PM - It Cannot Be Edited


Created By: Liza King On 08/28/2025 at 12:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 08/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/29/2025
Section Cited
CCR
87705(f)(5)

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(5) Interior and exterior space shall be available on the facility premises to permit residents with dementia to wander freely and safely. This was not met as evidenced by
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Licensee will ensure that dining area is open and supervision is provided immediately.
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Facility locks dining room of Memory Care area so that resdients cannot access this area during the day. This poses a potential risk to clients in care.
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Type B
09/11/2025
Section Cited
CCR87555

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87555(17) In facilities licensed for fifty (50) or more, and providing three (3) meals per day, a full-time employee qualified by formal training or experience shall be responsible for the operation of the food service. If this person is not a nutritionist, a dietitian, or a home economist, provision shall be made for regular consultation from a person so qualified. The consultation services shall be provided at appropriate times, during at least one meal. A written record of the frequency, nature and duration of the consultant's visits shall be secured from the consultant and kept on file in the facility. This was not met as evidenced by:
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Licensee agrees to have a diertery consultant visit the facility within 30days.
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The facility was unable to provide any records of consult visits from a Registered dietician or dierty consultant service. This poses a potential health and safety risk.
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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.
Krystall Moore
NAME OF LICENSING PROGRAM MANAGER:
Liza King
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2025


LIC809 (FAS) - (06/04)
Page: 6 of 11
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: 08/28/2025
NARRATIVE
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R3 had 3 incident report, 2 of which resulted from the resident themselves calling 911 for assistance due to pain and the third resulted in a higher level of care being needed. A review of the CPs provided and dated 3/13/25, 5/03/25 and most recently 5/28/25. 05/28/25 CP documents that a third party provider will provide and manage skin care. No showering or toileting assistance is provided on the 5/8/25 CP. Home Health documentation shows the resident was being seen by homehealth 2xwk for woundcare on four separate areas. Additionally, no interventions or frequency of homehealth is documented. The condition worsened requiring a higher level of care. The CP although updated did not document the change in condition including new or worsening wounds, facility oversite of care being provided and pain management. Additional follow up is needed and R3s resident records are being requested today to include the following: Admissions Agreement, Emergency Contact information, current and prior LIC602, Preadmissions appraisal, any reappraisal for the period of April 2025 to current, service notes for the period of April 2025 to current, any hospital discharge documents for the period of April 2025 to current, and MARs for the period of April 2025 to current, any documentation of communications to the responsible party or MD regarding reportable conditions.

R4 was hospitalized on 2 separate occasions in the past 6months. A review of medical records was conducted, CPs have been updated. Interventions are generalized and are not personalized ie there is a third party vendor in place to assist with management of skin care/wounds, however no description of the wound(s) locations, status, treatment or measurable goals are noted on the resident’s CP.

R5 additional follow up is needed. The RO has requested the licensee to collect and provide the Death Certificate by 10/01/25. Additionally, statements on the CP are not personalized ie “staff to provide diet as indicated on the dr order” (resident is on a texture modified diet which is not identified in the treatment/intervention area of the CP).

R6 had 4 falls from 5/2025 to 08/2025, 3 of which occurred during the same month. A review of the CPs was conducted which revealed that although the CP is documented as being updated, the generalized intervention remains, “staff will provide oversight and complete interventions to help reduce residents fall risk”. Interventions are not documented and the CP is not updated to address the fall risk. Additionally a change of condition CP was provided and dated 08/03/2025 which is incomplete and lacks problem statements and interventions.

cont.

NAME OF LICENSING PROGRAM MANAGER: Krystall Moore
NAME OF LICENSING PROGRAM ANALYST: Liza King
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC809 (FAS) - (06/04)
Page: 8 of 11
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: 08/28/2025
NARRATIVE
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R7 was sent to the ER due to agitation a change of medication was noted and 2 subsequent falls were reported. A review of the CP documents updates were made, however it is unclear what changes were made. Interventions do not include behavior modifications or monitoring for side effects of new medications which may have attributed to falls. Additionally, a review of R7s MARS for the months of June 2025 thru Aug 2025 was conducted and revealed on 6/26/25 am meds were not documented as being provided. Additionally an inhaler was not provided during the month of June, July or August. According to documentation provided by the facility and dated 03/15/25 the resdient had a high co pay therefore medications were not ordered. The facility was reminded that the facility should have paid for the medications and billed the resident or communicated with the physician to seek an alternative, In addition, medications were refused on the following dates, 07/11, 13, 16, 17, 17, 20, 25. No IR received for refused of missed medications, however communication was provided to the collaborative agency.

R8 has 4 unwitnessed falls from May 2025 to Aug 2025, one of which resulted in a fracture. A review of CPs, hosprpital DC documents, Hospice Admissions and Hospice Care Plan and MARS was conducted. Additional review is needed, additional documentation has been requested and received.

R9 had 3 falls from June to July 2025 one of which resulted in a fracture. A review of the CPs during that time period was conducted as well as hospital DC documents. Additional follow up is needed and R9s resident records are being requested today to include the following: Admissions Agreement, Emergency Contact information, current and prior LIC602, Preadmissions appraisal, any reappraisal for the period of April 2025 to current, service notes for the period of April 2025 to current, any hospital discharge documents for the period of April 2025 to current, and MARs for the period of April 2025 to current, any documentation of communications to the responsible party or MD regarding reportable conditions.

R10 over a 1 month period had 5 ER visits and is currently hospitalized. A review of the CPs and Mars for the same period was conducted. Additional follow up is needed. Additional follow up is needed and R9s resident records are being requested today to include the following: Admissions Agreement, Emergency Contact information, current and prior LIC602, Preadmissions appraisal, any reappraisal for the period of April 2025 to current, service notes for the period of April 2025 to current, any hospital discharge documents for the period of April 2025 to current, and MARs for the period of April 2025 to current, any documentation of communications to the responsible party or MD regarding reportable conditions.

cont.

NAME OF LICENSING PROGRAM MANAGER: Krystall Moore
NAME OF LICENSING PROGRAM ANALYST: Liza King
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC809 (FAS) - (06/04)
Page: 9 of 11
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: 08/28/2025
NARRATIVE
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R11 had 6 unwitnessed falls over a 2 month period. A review of the DC documents, CPs and MARs was conducted. Although CP documents fall risk and to ensure all staff are aware of fall risk, no specific interventions are noted just that they will be implemented. This is a generalized statement not specific to the care of this resident.

On 06/19/25 the department was notified of a resident on resident altercation via an incident report. The incident did result in a resident being sent to the ER no significant injury wass noted, however one resident does have a history of agitation. Any altercation should be submitted via a SOC341 and cross reported to all parties. Technical Assistance is provided.

An exit interview was conducted with designee Marilyn Otero, citations were issued and are attached on the D page. Appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Krystall Moore
NAME OF LICENSING PROGRAM ANALYST: Liza King
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC809 (FAS) - (06/04)
Page: 10 of 11
Document Has Been Signed on 08/28/2025 04:13 PM - It Cannot Be Edited


Created By: Liza King On 08/28/2025 at 01:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 08/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/03/2025
Section Cited
CCR
1569.2

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1569.2(c) provides:

(c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. The facility fails to do this as evidenced by a R:R altercation occuring in which one resident is known to require additional supervision.
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Updates are currently being made to the CPs to address behavioral expressions. An audit will be made of those resdients that have hx of agitation and a list will be made of the resdietns name and triggers to asssit staff in identifying when incidents may occur. In addition to triggers modiciations will be identified and documented on the audit. This will be provided to to Kesha.Lewis@dss.ca.gov.
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 An IR was received which documented a R:R altercation occuring in which one resident is known to require additional supervision.
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Type B
09/26/2025
Section Cited
CCR87463(3)

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(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This was not met as evidenced by
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Licensee will order air freshner for the area and continue with monthly shampooing of carpet.
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The MC area was malodorous this is a potentail risk to clients 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.
Krystall Moore
NAME OF LICENSING PROGRAM MANAGER:
Liza King
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2025


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