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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701388
Report Date: 03/27/2026
Date Signed: 03/30/2026 09:38:16 AM

Document Has Been Signed on 03/30/2026 09:38 AM - 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:		CAROLYN APPEALFACILITY TYPE:
740
ADDRESS:1321 S. FAIRMONT AVENUETELEPHONE:
(209) 334-3436
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 136CENSUS: 67DATE:
03/27/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:00 AM
MET WITH:Carolyn Appeal TIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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Today Licensing Program Manager Liza King and Licensing Program Analyst (LPA) Kesha Lewis made an unannounced visit to this facility to follow up on incident reports received from the facility and documentation requested by the Department. LPA and LPM met with the Administrator Carolyn Appeal. The purpose of the visit was explained.

Current census is 67 in hospital 5 on hospice 5

The Regional Office (RO) received an LIC624 on 03/17/26 re an incident that occurred on 3/16/26 for R1 and R2 in which an altercation between the two had occurred. The following documents were reviewed. Admissions Agreement, Emergency Contact Sheet, LIC602, Preplacement appraisal and any reappraisal, Needs and Services Plans, MAR for Jan 2026 to current , Any incident reports Jan 2026 to current , Any Service Notes for Jan 2026 to current, Any discharge summaries for Jan 2026 to current , Resident Roster, Staff Roster with telephone numbers. The incident resulted in R1 being injured. A review of the records revealed there was no update to the care plan. R1 had not been administered any pain medication, since return from the hospital more than a week ago. When LPM asked R1 how they were doing they expressed pain and were able to identify where.

Additionally the RO conducted a follow up visit re LIC 624 received for R3, R4, R5, R6, R8 in which falls occurred and residients were hospitalized. Similar documentation was requested from the licensee to be submitted to the RO by 03/26/26, proof of email was observed and documents were printed and provided during visit. The RO will review the documentation, conduct interviews and return at a later date to address any concerns.


NAME OF LICENSING PROGRAM MANAGER: Krystall Moore
NAME OF LICENSING PROGRAM ANALYST: Liza King
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2026
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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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)
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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: 03/27/2026
NARRATIVE
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Documented on several LIC624 was that the caregiver contacted another staff, hospice or a family member prior to calling emergency services (R7, R8). During todays visit three caregivers were interviewed and the all reported that if a resident falls and hits their head on the wall they are to call for a med tech to assess the individual. The caregivers reported they are not to call for emergency services that is the duty of the med tech. A request for the fall policy and emergency protocols was requested which documents any staff may call 911.

A tour of the facility was conducted of Memory Care (MC) the door to the laundry room and fire room were unlocked, as well as AL leaving the area with toxins accessible to residents. Additionally several rooms in Memory Care had personal care supplies accessible to residents in care. A review of the LIC602s revealed one or more of the residents were not allowed access to these items. A discussion with the Administrator confirmed that these areas should not have accessibility to personal care supplies, best practices were discussed. Staff were prompted to remove the items. Three doors were tested in MC one released with no alarm after the 15 second delayed egress standard. 2 rooms in MC were observed to have O2 with no warning sign and 1of2 were were improperly stored. More than 10 resident rooms in Al and MC were observed to not have hand soap for residents to wash their hands.

A tour of the outside was conducted the water heater closet smelled of gas the Administrator was prompted to call gas service, however Maintenance Director reported that a new water heater is being installed on Monday 03/30/26. Several screen doors were tested, some were unable to move freely. A screen was missing from a window. Hot water was tested ranging from 77 degrees to 125 degrees outside of the acceptable range. Various theromostats were observed at 66 degrees prior to 8am which is outside of the acceptable range.

A tour of the AL revealed the floor coming up in room 67, and in the med tech room, in MC with tape over the carpet. In AL a resident was observed with full bedrails. Broken washers and dryers were observed and being cited on a complaint 20260108144201.

A tour of the kitchen, adequate food present, breakfast and lunch service were observed with no concern. One broken freezer observed. Currently food is orders twice per week.

Citations and civil penalties are being issued today as a result of the visit. A review of the report is being provided and reviewed with Administrator Carolyn Appeal. Appeal rights were provided.

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

DATE: 03/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/30/2026 09:38 AM - It Cannot Be Edited


Created By: Liza King On 03/27/2026 at 10:22 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: 03/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/31/2026
Section Cited
CCR
87309(a)

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(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage...
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Doors were locked immediately. Administrator will look into a mechanism that locks automatically and send a plan to Kesha.Lewis@dss.ca.gov
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This was not met as evidenced by bleach and laundry supplies asscessible in both memory care and assisted living; all doors were open and accessible to resdients in care. This poses an immediate threat to the health and safety of resients in care.
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Type A
03/31/2026
Section Cited
CCR87309(b)

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(b) Residents may have access to items specified in subsection (a) for personal use unless there is documentation, as specified in Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, that indicates the resident's or other residents’ safety would be at risk if allowed access.
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The Administrator had staff remove all personal care Supplies immediately. Additionally the Administrator will audit the LIC602s to determine which residents can have access to supplies and place a identifying marker on their room. photos will be sent to Kesha.Lewis @dss.ca.gov by 03/30/26
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This was not met as evidenced by several resident rooms in memory care had personal care supplies such as soap, shampoo, body wash, toothpaste. 2 of 6 files reviewed showed the residents were not allowed access based on physician documentation. This poses an immediate threat to the health and safety of resients 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: 03/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/30/2026 09:38 AM - It Cannot Be Edited


Created By: Liza King On 03/27/2026 at 11:02 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: 03/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/31/2026
Section Cited
CCR
87463(g)

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(g) The licensee shall ensure corresponding changes are made in the care and supervision provided to the resident. This poses an immediate threat to the health and safety of resients in care.
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The Administrator documents changes in Alice on the daily tracker a random review of care plans will be implemented to ensure staff are adhereing to the needs.
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This was not met as evidenced by R1 was discharged with a fracture and prn pain medication. A review of the records revealed there was no update to the care plan. This poses an immediate threat to the health and safety of resients in care.
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Type A
03/31/2026
Section Cited
CCR87465(a)(4)

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(4) The licensee shall assist residents with self-administered medications as needed.
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The Admnistrator will implement a check in having the Med Tech ask residetns at med adminitration how they are feeling today. A copy of the new procedure and MT signoff of understanding will be provided to Kesha.Lewis
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This was not met as evidenced by R1 sustained a fracture. A review of records showed no Pain mangement medication provied for over 7 days. Interview with the resdietn revealed pain when asked how they were doing today. This poses an immediate threat to the health and safety of resients in care. This poses an immediate threat to the health and safety of resients 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: 03/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/30/2026 09:38 AM - It Cannot Be Edited


Created By: Liza King On 03/27/2026 at 11:20 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: 03/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/27/2026
Section Cited
CCR
87303

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(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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A sign in the kitchen was hung warning of hot water. Hot Water heater will be replaced on Monday. A plan to address flloring will be submitted to Kesha.Lewis@dss.ca.gov completion is estimated at 30 days.
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This was not met as evidenced by: 2of2 resdient rooms water tested at 77 and 76 degrees, kitchen sink water temperature tested at 125 degress. Flooring in the AL med Tech office, carpet in MC and flooring in AL rm 49 were all in need of repair. This poses an immediate threat to the health and safety of resients in care.
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Type A
03/27/2026
Section Cited
CCR87618(b)

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(3) Ensuring that the use of oxygen equipment meets the following requirements:...(B) "No Smoking-Oxygen in Use" signs shall be posted in the appropriate areas...
(E) Oxygen tanks that are not portable shall be secured in a stand or to the wall.
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This regulation was not met as evidenced by O2 canisters were not stored poperly in a stand and oxygen signs were not posted on the bedroom doors. This poses an immediate threat to the health and safety of resients in care.
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The Administrator agreed to safely secure all Oxygen canisters. Additionally signs will be posted on the exterior of any room which contains oxygen. Photos of proof of correction will be sent to Kesha.Lewis@dss.ca.gov
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: 03/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/30/2026 09:38 AM - It Cannot Be Edited


Created By: Liza King On 03/27/2026 at 11:42 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: 03/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/31/2026
Section Cited
CCR
87468.1

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(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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The Administrator will provide training to staff on redirecting residents who are exhibiting behavioral expressions
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This was not as evidenced by R1 being forcefully grabbed by R2 resulting in a fracture. This poses an immediate health and safety rsik.
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Type B
03/31/2026
Section Cited
CCR87608(5)(B)

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(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
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This was not met as evidenced by a resdient being observed by the LPM and Admin with full bedrails and no physicans order, exception or hospice services.
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The Administrator will have an review of all hospital beds conducted to ensure no other residents have full rails. The Administartor will obtain a physicians order and provide a copy to Kesha.Lewis@dss,ca,gov
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: 03/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/30/2026 09:38 AM - It Cannot Be Edited


Created By: Liza King On 03/27/2026 at 11:59 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: 03/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/31/2026
Section Cited
CCR
87307(a)(3)(D)

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(D) Hygiene items of general use such as soap and toilet paper.
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The Administrator agreed to purchase hand soap (nontoxic) and provide proof to Kesha>Lewis@dss.ca.gov
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This was not met as evidenced by the absense of a hand soap in resdietn rooms. This poses an immediate health and safety 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: 03/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2026


LIC809 (FAS) - (06/04)
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