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    Balance Assisted Living, Lodi

    1321 S Fairmont Ave, Lodi, CA, 95240
    4.4 · 59 reviews
    • Assisted living
    • Memory care
    For pricing and availability(510) 508-4507
    For the front desk(209) 334-3436
    AnonymousLoved one of resident
    4.0

    Caring facility with communication concerns

    I placed my mother here and overall it's a caring, clean community with attentive staff, tasty meals, lots of activities and solid memory-care - she's thriving. New owners have made nice renovations and can be responsive, but we experienced poor communication, medication mix-ups, staffing shortages/turnarounds and occasional outages/unfinished work that worried me. It's a good value with compassionate staff, but stay vigilant about care coordination and safety.

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    Amenities

    4.42 · 59 reviews

    Overall rating

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1

    • Care

      3.9

    • Staff

      4.5

    • Meals

      4.0

    • Amenities

      3.6

    • Value

      1.8

    Location

    Map showing location of Balance Assisted Living, Lodi

    About Balance Assisted Living, Lodi

    Balance Assisted Living & Memory Care in Lodi sits at 1321 S Fairmont Ave and offers a comfortable spot for adults aged 55 and over who want both independence and support, or who need memory care with extra safety. They have independent living options with studio and one-bedroom apartments, plus condos, senior townhomes, and apartments, some of which come fully furnished and have optional patios where folks can sit outside. There's single, semi-private, or shared units, and all residents can enjoy common rooms, a game room, a library, and a courtyard for outdoor events or listening to live music. Safety gets priority here-they've added medical alert systems and home security measures, and staff stay on site 24 hours to help with emergencies or moving someone from a bed to a wheelchair.

    For those who need help, Balance Assisted Living & Memory Care offers assisted living services, memory care for people with dementia or Alzheimer's, and companion care, all with licensed staff who build custom care plans and focus on dignity and respect. There are programs for memory support and ways to boost cognitive abilities, plus a secure environment for those who tend to wander. Help with bathing, dressing, and medication is provided along with personal care, housekeeping, laundry, and prepared meals. The staff works to meet everyone's needs and give each person choices for how they want to live. Respite care, aging in place, and hospice support are all available.

    Meals are made with care and the dining areas encourage folks to eat together and talk. Snacks show up during special events, and a beautician and barber are on hand, with a beauty salon, full tubs, and even devotional services onsite or offsite. Residents can join activities onsite or outdoors-there are nature trails by Lodi Lake, the chance for biking through BikeLodi, social gatherings, educational sessions, and off-site trips to wineries, shops, and restaurants. There's parking and transportation at cost, so staying active and connected is easier. The community gets decorated and festive during the holidays, and the place tries to feel as much like home as it can. Balance Assisted Living & Memory Care has earned a 3.8 rating from six reviews, showing they do fine in meeting most needs. The place takes part in the Assisted Living Waiver Program and is licensed as a Residential Care Facility for the Elderly, meeting California's regulations. All in all, Balance Assisted Living & Memory Care focuses on helping seniors maintain independence, feel comfortable, and stay connected with others while getting care that fits them, in a safe, warm setting.

    People often ask...

    State of California Inspection Reports

    179

    Inspections

    63

    Type A Citations

    54

    Type B Citations

    6

    Years of reports

    07 Jul 2025
    Identified an allegation that care staff were listed as CNAs when they were not certified nursing assistants.
    • §
    • § 9058
    06 May 2025
    Investigated nine residents’ incident reports dated 04/13/2025 to 04/18/2025; opened case management and requested needs and services plans, medical reports, care notes, and discharge paperwork. Returned later to review the documents and deliver findings; no citations were issued.
    • § 9058
    08 Apr 2025
    Found that staff complied with intervention and reporting rules for two falls on 03/10/2025 and 03/12/2025 after reviewing incident documents and discussing with the administrator.
    • § 9058
    08 Apr 2025
    Determined there was not enough evidence to prove violations of covid protocols, noting adequate PPE, sanitizers, and social distancing during outbreaks. Found hot water consistently available in the men’s bathroom and throughout, and that the emergency food supply was adequate.
    20 Dec 2024
    Identified an amendment to the pre-licensing capacity assessment after an unannounced visit, with an exit interview conducted with the administrator.
    19 Dec 2024
    Found in compliance at this time after a pre-licensing visit for a change of ownership, with 59 residents present and capacity to serve up to 136. Observed safe, clean spaces, proper exit access, charged extinguishers, a locked medication area, and adequate supplies; five resident records were reviewed with no deficiencies identified.
    26 Sept 2024
    Reviewed evidence and interviews related to a resident’s unwitnessed fall and subsequent injury, concluding that staff care and supervision were adequate and that the resident's falls were consistent with his mobility goals and condition.
    12 Sept 2024
    Identified that a former resident drank excessively, causing frequent intoxication and a tongue-biting incident with bleeding, and that a caregiver lacked required infection-control training, resulting in a civil penalty for a repeat violation within a year.
    12 Sept 2024
    Determined that staff member did not receive required infection control training after assisting a resident who experienced bleeding from biting his tongue during an intoxication incident, leading to citations and a civil penalty for repeat violations.
    • § 87463(a)
    • § 87470(c)(1)
    20 Aug 2024
    Identified extensive safety and maintenance deficiencies at the site, including exposed wiring, nonfunctional signaling and camera components, door and egress hardware issues, damaged rails, missing screens, cleaning and sanitation problems, pest control needs, and required updates to plans and sketches; the applicant has not yet passed the pre-licensing component.
    20 Aug 2024
    Found that a resident had multiple falls with ER visits, the home did not implement a fall prevention plan or update assessments after those falls, and a civil penalty was assessed for repeated violations.
    • § 87463(a)
    20 Aug 2024
    Identified a repeat violation within 12 months, resulting in a civil penalty of $1,000, and found that the assessment lacked a plan to address the sexual behaviors of a resident who is a registered sex offender. Identified a medication error when a med-tech left medication in a resident's room, creating an immediate health and safety risk.
    20 Aug 2024
    Found that a resident was physically abused by a staff member, witnessed by another staff member, with rough handling and a cart incident that created an unsafe environment. Identified ongoing aggression by a resident leading to injuries, incomplete and unsigned care plans, delays in medical care, and unsafe conditions such as lacking a staff-summon system and unsanitary outdoor areas.
    • § 87464(f)(1)
    • § 87303(a)
    • § 87464(f)(1)
    • § 87303(i)(1)
    • § 87413(a)(2)
    • § 87465(g)
    • § 87468.1(a)(2)
    20 Aug 2024
    Found numerous maintenance and safety issues, including exposed wires, damaged doors, missing screens, and outdated equipment, that needed to be addressed before the facility could meet licensing standards.
    20 Aug 2024
    Identified a recurring violation related to resident management and a significant medication safety incident involving a resident, leading to a civil penalty and noting deficiencies in safety planning.
    • § 87463(a)
    • § 87470(c)(1)
    16 Aug 2024
    Found that one staff member spoke to another in an inappropriate manner in an office on the memory care unit, and that their loud conversation could be heard by residents, compromising residents' dignity in their interactions with staff.
    15 Aug 2024
    Determined that a resident sustained multiple injuries while in care due to inadequate supervision. A civil penalty of $9,500 was issued for serious bodily injury, following an earlier $500 penalty.
    16 Aug 2024
    Identified that staff did not inform the resident's responsible party when the resident was taken to the ER on August 5, 2024. Led to a civil penalty for repeating the same violation within 12 months.
    • § 87211(a)(1)
    16 Aug 2024
    Investigated inappropriate and loud conversations between staff members occurring publicly, which compromised residents’ dignity.
    • § 87468.1(1)
    01 Aug 2024
    Confirmed the TSP process was explained and audit findings were shared during a Teams meeting. Identified discussions covered record keeping, care and supervision, and medication management, with no deficiencies cited.
    15 Aug 2024
    Confirmed that residents suffered serious injuries due to inadequate supervision, resulting in a civil penalty for the violation of safety and reporting requirements.
    • § 87457(c)(1)
    • § 87465(h)(2)
    01 Aug 2024
    Confirmed that the program staff understood the TSP process and that no deficiencies were identified related to record keeping, care and supervision, or medication management during the recent review.
    31 Jul 2024
    Found that a resident with dementia had multiple ER visits for falls, including one linked to an altercation with another resident, and health status changes were not adequately reflected in needs and service plans. An immediate civil penalty was assessed and is under review.
    • § 87705(c)(5)
    31 Jul 2024
    Identified deficiencies included failure to report a resident-on-resident abuse incident and multiple falls to licensing, failure to update a resident’s health reappraisal after significant health changes, personal-rights concerns about unsafe accommodations leading to injuries from a resident-on-resident altercation, and unsafe medication handling with a pill found on the floor.
    31 Jul 2024
    Identified that after admission to a care setting, essential assessments and reappraisals were not completed, leaving health changes unmonitored and contributing to falls, a left hip fracture, hospitalizations, and death. Planned to assess an immediate civil penalty of $1,000 due to a repeated violation affecting health and safety.
    • § 87464(f)(1)
    • § 87211(a)(1)
    31 Jul 2024
    Identified multiple reporting violations related to resident falls and altercations, leading to civil penalties, and found that residents' health changes were not properly reappraised, while also noting safety concerns such as a medication pill on the floor.
    16 Jul 2024
    Identified that a resident requested to speak with the analyst; the analyst arrived unannounced, explained the purpose, met with staff, and an exit interview was conducted.
    12 Jul 2024
    Identified that four residents did not receive their medications during routine medication passes. A civil penalty was assessed.
    16 Jul 2024
    Reviewed a resident’s request to speak with an analyst, leading to an unannounced visit and an exit interview with the facility.
    12 Jul 2024
    Identified the following allegations: no activities were provided on July 11–12 and snack socials and snacks were not consistently offered; a common-area refrigerator had a broken door handle, frost buildup, no thermometer, and questionable fruit cup expiration, with no snack check logs; a nail was found in a serving platter; and air conditioning problems required portable units.
    • § 87303(a)
    • § 87219(a)
    • § 87555(a)
    12 Jul 2024
    Identified multiple violations related to activity provision, snack monitoring, refrigerator maintenance, and air conditioning issues, leading to a civil penalty due to repeated violations within 12 months.
    • § 87468.1(1)
    03 Jul 2024
    Identified ongoing non-compliance since 2019, including staffing concerns, medication errors, and safety issues, with numerous citations and complaints.
    18 Apr 2024
    Identified allegations of staffing shortages, scheduling issues, medication errors, and fire clearance problems. No deficiencies cited during the visit.
    03 Jul 2024
    Identified multiple ongoing compliance issues related to staffing, medication management, resident care, and facility operations, leading to a non-compliance conference emphasizing future enforcement actions.
    21 Jun 2024
    Confirmed applicants and administrator read and understood licensing laws, including the Health and Safety Codes and Title 22. Conducted exit interview with applicants and administrator; confirmed understanding of license type, client populations, admission policies, staffing requirements and training, restrictive or prohibited health conditions, general provisions, emergency preparedness, complaints and reporting, and pre-licensing readiness.
    21 Jun 2024
    Confirmed that applicants and administrator participated in COMP II via virtual interview, identities verified, and understanding of applicable laws and regulations. Conducted an exit interview with applicants and administrator and reviewed topics including license type, resident populations, admission policies, staffing and training, health condition restrictions, general provisions, emergency preparedness, complaints and reporting, and pre-licensing readiness.
    21 Jun 2024
    Found that a resident received oxycodone beyond the prescribed order and did not receive timely medical attention during a painful episode, resulting in serious bodily injury. Penalties related to the harm were under consideration.
    21 Jun 2024
    Determined that the complaint of a questionable death was unfounded. Death certificate listed respiratory failure, congestive heart failure/volume overload, sepsis, and an infected left hip as the causes.
    21 Jun 2024
    Confirmed that applicants and the administrator successfully completed the required competency interview, demonstrating understanding of licensing laws, community care practices, emergency procedures, and operational policies.
    21 Jun 2024
    Confirmed that applicants and the administrator understood licensing laws, facility operations, staffing, emergency readiness, and reporting requirements during a virtual interview related to a change in ownership for a residential care setting with 69 clients.
    20 Jun 2024
    Investigated found that a resident suffered multiple unwitnessed falls resulting in serious injuries and emergency hospital care due to insufficient supervision and care. Identified that the resident's Needs and Services Plan was not reassessed or updated after falls, and written incident reports were not provided to the responsible party as required.
    • § 87464(f)(1)
    • § 87466
    • § 87211(a)(1)
    20 Jun 2024
    Determined that residents experienced multiple un-witnessed falls and serious injuries due to inadequate supervision and failure to update care plans, resulting in violations of reporting requirements and neglect of residents' changing needs.
    • § 87465(a)(4)
    11 Jun 2024
    Identified missing medical records for a resident during an unannounced visit. Received partial records later, a citation was issued, and an exit interview occurred.
    11 Jun 2024
    Investigated the allegation of retaliation; found staff did not experience retaliation and feel comfortable reporting concerns. Not a preponderance of evidence to prove the allegation occurred or did not occur, so the allegation remains unsubstantiated.
    11 Jun 2024
    Reviewed that the facility failed to provide complete resident records, resulting in an inspection authority citation.
    29 May 2024
    Identified that R1's appraisal/needs and service plan had not been updated to reflect current health status and needs. Exit interview conducted with staff.
    • § 87463(a)
    29 May 2024
    Investigated allegations that a resident’s UTI and sepsis resulted from being left in soiled briefs and inadequate grooming; not supported by the evidence. Identified inconsistencies in incontinence care documentation and an outdated needs and services plan.
    29 May 2024
    Reviewed resident 1's health records and found that their Appraisal/Needs and Service Plan had not been updated to reflect current health needs, leading to a citation for reappraisal deficiencies.
    • § 87465(g)
    • § 87465(a)(4)
    • § 87465(a)(6)
    29 Apr 2024
    Identified gaps in staff records, with five of ten files missing first aid, health screening reports, and TB results. Identified ten resident files as complete; noted a hospice waiver for 20 and delayed egress at memory care, with 63 residents.
    29 Apr 2024
    Reviewed resident and staff files during an annual inspection, noting that half of the evaluated staff files were missing some required documents; also confirmed compliance with infection control and disaster plans, and scheduled a follow-up visit.
    22 Apr 2024
    Found that a resident's controlled medication was given to another resident in error, and that five pills were ingested. Found that the administrator's behavior toward staff and external agencies' staff was non-professional, demeaning, and aggressive, with these allegations supported by the preponderance of the evidence.
    22 Apr 2024
    Found an eviction-without-notice allegation; the resident was not evicted and no eviction letter was provided, and the resident is returning after hospitalization with care planning involving an outside agency.
    22 Apr 2024
    Investigated whether a resident was evicted due to behavioral issues; found the resident was not evicted and is expected to return, resulting in insufficient evidence to confirm or deny the allegation.
    • § 87755(c)
    18 Apr 2024
    Reviewed non-compliance issues related to staffing, safety, resident services, and regulatory violations, resulting in a formal conference to address ongoing concerns and plan for future improvements.
    • § 87463(a)
    • § 87465(h)(2)
    • § 87211(a)(1)
    • § 87468.1(a)(2)
    15 Apr 2024
    Found that the allegation that residents were not served meals daily was not supported by evidence; five residents reported daily meals, two kitchen staff confirmed three meals per day, observed lunch portions were adequate, and food deliveries were regular.
    15 Apr 2024
    Reviewed evidence indicating residents received three meals daily with adequate portions and sufficient food supplies, suggesting no violation of feeding practices.
    • § 87464(f)(1)
    08 Apr 2024
    Investigated the Allegation that personal property was not safeguarded and that staff did not communicate with the resident's authorized representative; identified incomplete forms and missing documentation, including a physician report and preplacement information, with gaps about the resident's ambulatory status. Found there was not enough evidence to prove these specific allegations.
    08 Apr 2024
    Found that, after interviewing involved parties and reviewing records, the specific allegation could have occurred, but the available evidence did not establish whether it happened.
    08 Apr 2024
    Reviewed incident reports and conducted interviews, concluding there was not enough evidence to confirm whether the allegation of abuse or neglect occurred.
    • § 87411(f)
    • § 87411(c)(1)
    04 Apr 2024
    Identified staffing gaps in memory care, including no dedicated activity director and inconsistent on-call coverage. Found safety and medication concerns, such as unlocked chemicals, overdue fire extinguisher maintenance, a non-working call pendant, and a new-resident medication access problem where meds were unavailable for up to seven days.
    • § 87203
    • § 87465(a)(4)
    • § 87705(f)(2)
    • § 87303(i)(1)
    04 Apr 2024
    Investigated and found that staff indicated residents were not kept from seeking medical attention and were sent to the ER when requested or needed; memory care unit had no hospital admissions, while three residents in the other unit were hospitalized and two were placed at SNFs. Found no preponderance of evidence to prove the allegation that residents were prevented from obtaining medical care.
    04 Apr 2024
    Identified an allegation that a resident's bathroom plumbing was not in good repair and that the shower had a dirty film on the floor. Found the allegation valid and that a $1,000 civil penalty was assessed for repeating the violation within 12 months.
    • § 87303(a)
    04 Apr 2024
    Found that residents were not prevented from seeking medical attention, with residents either sent to the emergency room or admitted to facilities as needed, and concluded that there was insufficient evidence to determine whether the specific allegation was valid.
    29 Feb 2024
    Found insufficient evidence to determine whether the narcotics theft allegation occurred. Noted that MARs for several months were missing and no narcotics log was available, but interviews and a review found no confirmed missing medications and staff training appeared up to date.
    14 Mar 2024
    Investigated the allegation that a resident was left in soiled bedding or briefs. Interview with the resident indicated they are independent and able to manage toileting, and there was insufficient evidence to prove or disprove the allegation.
    14 Mar 2024
    Identified that resident records were not readily available at the home during the investigation; a citation was issued. The requested documents, including the admission agreement and billing statements, were later provided.
    • § 87755(c)
    14 Mar 2024
    Found insufficient evidence to determine whether the resident's records were readily accessible and whether a 30-day move-out notice was properly issued or charged.
    14 Mar 2024
    Confirmed that a deficiency was identified regarding the facility's failure to readily provide resident records during an inspection follow-up. The issue resulted in a citation and required additional documentation from the management company.
    06 Mar 2024
    Identified a mismatch between a physician's order for a soft, bite-sized diet with one-to-one supervision and the resident's actual meal supervision in a group setting. Issued a citation; the resident was to receive a one-to-one caregiver for all meals, and staff would contact the physician to discuss potential modifications to the order.
    06 Mar 2024
    Found insufficient evidence to determine whether the allegation that staff threatened residents occurred. Residents reported they had not witnessed or experienced threats from staff.
    06 Mar 2024
    Found an allegation of improper medication administration and delayed health monitoring for a resident. Evidence showed missing MAR entries for Melatonin, late blood pressure checks after PCP orders, and miscommunication with the responsible party, resulting in a $1,000 civil penalty for a repeat violation.
    • § 87465(a)(4)
    06 Mar 2024
    Investigated whether staff threatened residents; residents reported they had not witnessed or experienced threats. Concluded there was not enough evidence to confirm the allegation.
    29 Feb 2024
    Identified concerns about breakfast, including no fruit and meals served in Styrofoam containers that did not keep food warm or protect safety and nutritive value. Also noted that a meal menu began in February 2024, with the March 2024 menu first provided to residents that month.
    29 Feb 2024
    Identified kitchen sanitation and meal service concerns, including dirty mop water, debris on the floor, garbage under the sink, a faulty hot water faucet, meals served in Styrofoam that did not keep food warm, and no procedures to maintain safe food temperatures, with breakfast lacking fruit or meat. Identified an allegation that a resident was not fed by care staff during a meal.
    • § 87555(b)(9)
    • § 87555(b)(6)
    • § 87555(b)(a)
    • § 87303(a)
    29 Feb 2024
    Found that the unlawful eviction allegation was unfounded. Resident exhibited aggressive behavior toward self, staff, and other residents, leading to law enforcement involvement, hospital transfer, and self-discharge on February 9, 2024.
    29 Feb 2024
    Identified a foul urine odor in the memory care unit during carpet cleaning, and the odor allegation was determined valid.
    29 Feb 2024
    Identified a specific allegation that medications were not ordered timely, causing residents to miss doses and leaving inconsistent documentation of the reasons. Also found unsafe patio conditions, including a trench covered with loose boards and a broken awning pole.
    • § 87303(a)
    • § 87211(a)
    29 Feb 2024
    Found nine residents were on hospice and that residents or their responsible parties could choose their own hospice company, with three parties not contacted. Found insufficient evidence to determine whether the specific allegation about hospice company selection occurred.
    29 Feb 2024
    Identified specific allegations of medication administration gaps (AM shift for 9 days and PM shift for 2 days), inconsistent blood glucose monitoring, a strong urine odor in memory care, and carpet odor concerns.
    • § 87465(a)(4)
    • § 87625(b)(3)
    29 Feb 2024
    Identified insufficient information about who eloped; searches of police records showed no missing-person reports around the date; AWOL incident reports were not submitted. Found insufficient evidence to determine whether the elopement occurred.
    29 Feb 2024
    Confirmed the presence of a foul urine odor in the memory care unit, with staff indicating that a deep cleaning of carpets was underway. The allegation regarding unsanitary conditions was found to be valid.
    • § 87405(d)(5)
    • § 87465(a)(4)
    02 Feb 2024
    Found that the allegation that staff did not provide adequate food service resulting in death from malnutrition was unfounded. Medical and hospice records showed the resident consumed varying portions of meals, sometimes refused food, hospice visits occurred regularly, and death was due to other causes.
    02 Feb 2024
    Reviewed, the investigation determined that the resident’s death was not caused by malnutrition or inadequate food provision, with evidence showing they consumed meals regularly and received appropriate care.
    17 Nov 2023
    Identified issues from a complaint investigation, including under-staffing, needs and services plan, activity program in memory care, dementia plan and training, and change of ownership. Concluded no deficiencies were cited.
    08 Jan 2024
    Identified safety and maintenance issues, including a large glass window leaning against a resident patio fence, a faulty exterior water heater storage door with exposed wiring, missing fence boards on the memory care exterior patio, and an interior dementia unit exit door in disrepair. All identified concerns were cleared.
    08 Jan 2024
    Found that several safety and maintenance issues, including broken doors, missing fence boards, and exposed wiring, were corrected within the required timeframe.
    04 Jan 2024
    Identified a memory care resident’s elopement risk and an October 2023 incident in which the resident left the unit and was escorted back by local law enforcement. Found multiple safety and maintenance deficiencies, including unsecured exterior perimeters and patios, missing fence boards, doors that allow access to neighboring areas, exposed wiring, debris on walkways, and several door/roof maintenance issues.
    04 Jan 2024
    Reviewed safety and security concerns related to resident elopements and facility deficiencies, including broken doors, unsecured patio areas, hazards, and inadequate monitoring, with plans for corrective actions to address immediate risks.
    26 Dec 2023
    Identified that the allegation of not conforming with Fire Marshall standards due to hazardous objects and fire-loading materials was supported by evidence. Noted that the allegations of unsanitary conditions and of uncleared adults having access to residents were not supported.
    • § 87303(a)
    • § 87203
    • § 87202(a)
    26 Dec 2023
    Identified hazards related to blocked exits, clutter, and unsafe materials inside and outside the building, as well as unsanitary conditions involving trash and spoiled food, leading to findings of violations; verified that unauthorized adults did not have access to residents.
    • § 1569.2(c)
    15 Dec 2023
    Identified incomplete August 2023 medication administration records for a resident, with blank entries for a daily diuretic and a missing administration on one day, and unclear September–October 2023 records lacking year details. Found that a consent to change the resident's pharmacy was not completed, an emergency refill was requested from a non-approved pharmacy, and a billing issue occurred, indicating the resident did not have the right to choose that pharmacy.
    • § 87465(a)(4)
    • § 87468.2(a)(18)
    15 Dec 2023
    Found that medical record documentation was incomplete and that a resident's pharmacy was changed without proper consent, violating resident rights and regulations.
    04 Dec 2023
    Identified that two residents transferred from another location arrived with outdated medical files and admission documents tied to the former facility, and their belongings had not been transferred. Noted that they required a higher level of care and were not appropriate for the current site, and that reassessments had not been completed, with further information needed.
    04 Dec 2023
    Found that two staff had previously resided in rooms 44 and 70, but there was not enough evidence to prove whether the alleged violation occurred or not.
    04 Dec 2023
    Reviewed, staff belongings were not stored in rooms 44 and 70, and staff residing there are currently fingerprint cleared; although staff previously resided in those rooms, there was not enough evidence to confirm the allegation.
    30 Nov 2023
    Identified an incident in which three residents left the home unattended on 10/25/2023, and staff did not redirect them or notify other care staff. Found inconsistent medical reports—later updated to show some residents could leave unassisted—while no health and safety plan for driving existed and proper assessments were not conducted.
    • § 87463(a)
    • § 1569.312(e)
    30 Nov 2023
    Identified that staff failed to prevent residents who were not able to leave the facility unattended from doing so, and found the facility did not conduct proper assessments or implement safety plans related to residents' ability to leave or drive.
    • § 87303(a)
    • § 87405(a)
    • § 87463(a)
    • § 87411(a)
    • § 1569.312(e)
    21 Nov 2023
    Investigated an incident in which three residents left the home for a community outing, with two unable to be left unattended. Collected available health certifications and assessments and requested the missing documents by the next morning.
    21 Nov 2023
    Reviewed an incident involving residents leaving the premises on 10/25/2023; incomplete assessments were identified, and follow-up documentation was requested.
    17 Nov 2023
    Identified non-compliance issues related to staffing, administrator qualifications, and resident care requirements, with discussions focusing on steps to improve compliance, including hiring additional staff and updating training programs.
    25 Oct 2023
    Found that a resident sustained serious injuries after an assault by another resident, with two caregivers supervising about 29–33 residents and not in the area where the incident occurred. Identified ongoing safety concerns due to resident-to-resident aggression, lack of safety measures, a prior similar violation within 12 months, and civil penalties of $1,000 immediate and another $1,000 pending review.
    25 Oct 2023
    Identified deficiencies in administrator qualifications, inadequate staffing, and reporting requirements. Found that a July 22 incident left residents unsupervised and resulted in serious injuries, with ongoing understaffing and supervision gaps in common areas, and noted repeated delays in submitting required unusual incident reports to licensing authorities, including October 2023 events.
    25 Oct 2023
    Found that a resident sustained serious injuries after being assaulted by another resident due to inadequate supervision and insufficient staffing, despite a history of resident aggression and prior violations.
    03 Oct 2023
    Identified during an unannounced quarterly visit that staff training was ongoing, the administrator was present full-time, and schedules and resident care documents were reviewed. Confirmed that an architect had been engaged, weekly management meetings were held, and there was ongoing communication with the management company.
    03 Oct 2023
    Reviewed staff training records, resident care plans, and facility policies; confirmed ongoing communication with management and engagement with external professionals for construction plans.
    • § 87464(f)(1)
    13 Sept 2023
    Determined there was no evidence that staff pinched noses or tipped heads to administer medications, and no evidence of insulin mismanagement. These medication-related concerns remained in line with previous findings.
    13 Sept 2023
    Found no bed bug issue here; the related incident report belonged to a different location.
    13 Sept 2023
    Reviewed allegations that staff were improperly assisting residents with medication, including nose plugging and head tipping, as well as concerns about insulin administration; interviews and observations indicated these claims were not supported by evidence.
    • § 87405(h)(5)
    • § 87411(a)
    • § 87211(2)
    31 Aug 2023
    Found that the allegation of inadequate supervision of residents by staff was unsubstantiated, and that the allegations of inadequate food service, inadequate laundry service, poor cleaning, unmet hygiene needs, and disrepair were unsubstantiated.
    31 Aug 2023
    Identified two AWOL incidents on 07/25/23 and 08/14/23 involving a resident found outside without assistance, with the 08/14/23 incident occurring about 1.5 miles away. Noted staffing shortages in memory care (one med tech and two caregivers per shift with no substitutions when staff called out) and concerns that alarms may have been turned off.
    31 Aug 2023
    Reviewed incident reports indicating Resident 1 left the premises without assistance on two occasions, despite medical restrictions. Identified staffing shortages and potential security lapses that may have contributed to the resident's unauthorized absences.
    24 Aug 2023
    Investigated five specific allegations: not changing residents timely; not offering alternative meals; not reporting resident falls; taking residents’ pendants; and being rough with residents. Found these allegations unfounded; evidence showed residents received timely care, alternative meals were available, falls were reported, pendants remained with residents, and no rough handling was observed.
    24 Aug 2023
    Investigated allegations that residents were not being changed timely, staff did not offer alternative meals, staff failed to report falls, took pendants away, and were rough with residents; found no evidence to support any of these claims.
    01 Aug 2023
    Identified deficiencies related to care and supervision, incidental medical care, personal rights, and maintenance and operation. Initiated nine-month follow-up to re-evaluate compliance and possible enforcement if issues persist.
    28 Jul 2023
    Identified ongoing construction without a permit, outdoor hazards such as hoses and debris, missing screens on some windows and doors, and pests near an entrance, with a stop-work order in place. Found that a random check of residents' rooms showed no issues with sliding doors or windows, and residents reported no problems.
    • § 87303(a)
    01 Aug 2023
    Reviewed issues related to licensing compliance including care, resident rights, and operation standards, with discussions on ongoing deficiencies and future monitoring plans.
    28 Jul 2023
    Found ongoing construction issues without proper permits, along with safety hazards such as tripping hazards, construction debris, missing window screens, and pests; these conditions led to citations for violations of health and safety regulations.
    12 Jul 2023
    Identified safety concerns during the visit, including chairs near exit doors, plywood blocking an entrance, and a missing door alarm in memory care. Identified an allegation that safety improvements had not been completed, and noted that additional civil penalties will be assessed.
    12 Jul 2023
    Found that after a recent construction, safety barriers remained in place despite instructions to remove them, and doorway alarms in the memory care area had not been replaced as scheduled; additional penalties are being considered due to unresolved safety concerns.
    09 Jul 2023
    Found a medication cart left unlocked in the hallway with no staff present and a fire suppression system out of compliance with state requirements (last serviced in 2021); civil penalties were issued. An exit interview was conducted and appeal rights were provided.
    09 Jul 2023
    Found that a medication cart was left unlocked without staff present and that the fire system was out of compliance, leading to citations with civil penalties.
    • § 87705(c)(4)
    07 Jul 2023
    Identified construction began without proper permits and public notice, with hazards including outside debris, non-functioning exit signs, inadequate ventilation in the lobby area, and fencing blocking an exit. A $500 civil penalty was assessed.
    07 Jul 2023
    Found that construction started without proper permit and notification, leading to a civil penalty and citations for safety violations, including unsecured areas, missing signage, and lack of public warnings.
    • § 87405(a)
    10 May 2023
    Investigated allegations that changes in the resident's condition were not observed or reported and that pressure injuries occurred while in care, with concerns about weight loss. Review of medical and home health records and interviews showed changes were noted by providers and family was kept informed; weight loss could not be confirmed due to weighing refusal, and there was insufficient evidence to determine if the allegations occurred.
    • § 87465(a)(2)
    • § 87466
    02 Jun 2023
    Found failure to provide timely medical care and lack of observation at the site.
    • § 87465(a)(2)
    02 Jun 2023
    Investigated concerns about the facility's failure to provide timely medical care and proper observation, conducting interviews and reviewing records; found staff received necessary training but did not submit required documentation on time.
    • § 87203
    25 May 2023
    Investigated allegations that a resident suffered multiple pressure injuries, including a stage-3 wound, with delayed medical care and inadequate pain management because the responsible party would not authorize hospital or emergency care; interviews indicated staff were aware of the injuries and the resident's pain. Reviewed records showed a needs and services plan from January 2022 that was unsigned and did not address wound care or pain management.
    25 May 2023
    Investigated concerns about pressure injuries and pain management for a resident, revealing delays in medical treatment due to family refusal of emergency services and inadequate documentation of care plans.
    • § 87305(a)
    • § 87211(a)(1)
    12 May 2023
    Determined there was not a preponderance of evidence to prove the theft of money or the missing nightgowns occurred; interviews with residents found no related incidents, and the suspected staff member was no longer employed.
    12 May 2023
    Investigated a theft allegation regarding missing nightgowns; found no evidence to support that theft occurred or that staff was involved.
    • § 87203
    • § 87465(h)(2)
    10 May 2023
    Determined that staff did not observe or report R1’s declining condition, which was attributed to health issues and noncompliance rather than staff neglect, and found insufficient evidence to confirm that R1 sustained pressure injuries or lost significant weight while in care.
    21 Apr 2023
    Investigated the allegation of neglect/lack of care and supervision resulting in a resident's fractured left wrist. Found that the cause could not be determined and there were no witnesses, so the allegation could not be proven.
    21 Apr 2023
    Found that staff did not adequately report a change in the resident's condition to the responsible party and delayed seeking medical attention after swelling was noticed, causing undue suffering.
    21 Apr 2023
    Investigated whether neglect or lack of care led to a resident's fractured wrist, but unable to determine how the injury occurred, resulting in an unsubstantiated finding.
    27 Mar 2023
    Found no deficiencies. Observed one refrigerator not functioning today and two others at 38°F, smoke detectors interconnected with the fire department, and an adequate food supply.
    27 Mar 2023
    Confirmed that the facility maintained a safe environment with adequate staffing, supplies, and functioning safety systems, despite one refrigerator being out of service. No deficiencies were identified during the inspection.
    • § 87463(a)(3)
    • § 87405(h)(5)
    • § 87615(a)(1)
    07 Mar 2023
    Found no evidence to support Allegation 1 that staff left residents unattended for an extended period; Allegation 2 that requests for assistance were not responded to in a timely manner; Allegation 3 that communication with residents’ representatives was delayed; and Allegation 4 that lighting was inadequate.
    07 Mar 2023
    Investigated four allegations related to resident safety and communication, none of which were supported by the evidence; staff were observed attending to residents promptly, communication with residents’ representatives was timely, and the lighting was adequate throughout the facility.
    07 Feb 2023
    Identified an unannounced visit, reviewed air conditioning repair records showing the system was fixed on 9/2/2022, and conducted an exit interview with appeal rights provided.
    07 Feb 2023
    Identified nonfunctional air conditioning in the back memory care area, with portable units deployed and hydration stations available throughout. Found insufficient evidence to prove that residents' rooms were dirty, that staff barricaded residents in memory care, or that residents were left in soiled diapers for an extended period.
    • § 87303(b)
    07 Feb 2023
    Investigated complaints about inadequate air conditioning, dirty resident rooms, residents being barricaded in memory care, and prolonged soiling of diapers; findings indicated the air conditioning was in disrepair, but resident rooms appeared clean, and there was no evidence of residents being barricaded or left in soiled diapers.
    • § 87466
    • § 87464(f)(1)
    06 Jan 2023
    Found that certified administrator coverage did not meet the required standard, despite a 10-21-21 meeting establishing the need for coverage. LIC 500 showed a Tuesday–Saturday schedule from 9:00 a.m. to 5:30 p.m., yet interviews indicated coverage occurred only 2 days per week; a civil penalty of $250 was issued for a repeat violation within 12 months.
    • §
    06 Jan 2023
    Determined that the certified Administrator was not on duty as required by the department, with records showing the Administrator worked only two days per week instead of the scheduled days. A civil penalty was issued for a repeat violation within 12 months.
    13 Dec 2022
    Reviewed incident and medical records for the home, identifying unwitnessed falls for two residents and a stage 3 pressure sore for another resident who was receiving hospice care. Found that 9-1-1 was called for medical intervention after the falls, fall-prevention measures and call pendants were in place, staffing levels were appropriate on the dates reviewed, and a hospice waiver was in effect; no deficiencies were cited.
    13 Dec 2022
    Determined that a resident was hospitalized on 11-23-22 due to concerns of blood in the urine, and that no incident report or notification to the responsible party and physician was submitted. Issued a citation and conducted an exit interview with the administrator.
    13 Dec 2022
    Found that a resident showed blood in urine beginning 11-13-22 and did not receive timely medical care, resulting in hospitalization on 11-23-22; additionally, the resident’s authorized representative and physician were not adequately notified.
    13 Dec 2022
    Reviewed incident reports indicating that residents experienced unwitnessed falls with appropriate medical responses and fall prevention measures in place, as well as a resident with a pressure sore receiving proper hospice wound care. No deficiencies were identified during the visit.
    02 Dec 2022
    Found that hot water was not delivered from faucets starting 11-11-22 in a hallway area, affecting residents’ bathing needs. Service personnel were contacted on 11-14-22 and the water heater, a residential unit, was found to be unsuitable.
    02 Dec 2022
    Determined that the facility knew about hot water issues caused by a malfunctioning water heater starting on 11-11-22 but did not take adequate action to ensure residents received hot water after the problem was identified.
    • § 87466
    • § 87465(a)(1)
    18 Nov 2022
    Identified lack of a full-time acting administrator (40 hours per week) and no designated substitute, with a new interim administrator of record recently hired but not yet started. Found hot water loss from a malfunctioning water heater beginning 11-12-22, repairs completed by 11-14-22, hallway temperatures testing 105–120°F, and one COVID-19 case not reported to the licensing agency within 24 hours.
    18 Nov 2022
    Found that hot water issues and lack of timely COVID reporting occurred, and the facility did not have a designated on-duty administrator or substitute as required.
    21 Apr 2022
    Found the eviction letter contained all required elements, and interviews and records showed the resident engaged in an action that violated house rules and posed a potential health and safety risk. Concluded eviction allegation unsubstantiated.
    21 Apr 2022
    Reviewed an allegation of illegal eviction and found the resident's actions violated house rules and posed a safety risk; the eviction letter contained all required elements.
    • § 87211(a)(1)
    25 Mar 2022
    Found the allegation that four residents with scabies were admitted unfounded. Audits showed adequate finances, a brief service outage unrelated to the home, and that the residents were treated on arrival and cleared of scabies.
    25 Mar 2022
    Determined that the allegations related to resident health and facility finances were unfounded after inspections and a financial audit, concluding no issues with the facility’s resources or management.
    • § 87303(e)(2)
    21 Mar 2022
    Identified two deficiencies: fire drill log not provided and staff health screening/TB documentation missing. Observed safety measures and conditions, including interconnected smoke detectors, hot water temperatures around 114–120 degrees, and adequate food supplies.
    21 Mar 2022
    Identified deficiencies included the inability to produce a fire drill log and missing health screening or TB test documentation for staff, during an inspection of the facility licensed to serve residents with specific health needs.
    17 Feb 2022
    Found that a staff member did not protect a resident from another entering the room, including an incident where one resident was found sleeping in another resident's room wearing only boxers. Medications were signed as given on administration records, with no documented refusals.
    17 Feb 2022
    Investigated whether staff failed to protect a resident from another resident entering their room and whether a resident's clothing was removed by another resident; found insufficient evidence to confirm the allegations regarding clothing removal, but confirmed that a resident was found sleeping with only boxers in another resident’s room.
    19 Nov 2021
    Identified safety hazards at the site, including laminate flooring in two resident rooms that had become unglued from the subfloor and a loose door strikeplate creating trip hazards. Determined the safety hazard allegations to be valid.
    • § 87303(a)(1)
    19 Nov 2021
    Confirmed that unsafe flooring and a loose door strikeplate posed trip hazards, leading to a finding that the allegation regarding unsafe conditions was validated.
    • §
    • §
    • §
    • §
    21 Oct 2021
    Identified management changes and ongoing COVID protocol concerns, including staff not wearing masks, failure to report positive resident cases, and misinterpretation of visitor guidance. Noted past COVID-related citations and emphasized adherence to COVID rules and reporting requirements.
    21 Oct 2021
    Found no deficiencies related to the stated allegation after reviewing records and interviewing staff.
    21 Oct 2021
    Reviewed records and interviewed staff during an unannounced visit related to a complaint investigation, with no deficiencies observed or cited.
    • § 1569.695(c)
    • § 87412(a)(11)
    17 Sept 2021
    Identified a case management deficiency for failure to report an incident as required, involving five residents who tested positive for an infectious disease on 08/11/21 and were not reported until 08/18/21. Appeal rights were provided and an exit interview was conducted.
    • § 87211(a)(2)
    17 Sept 2021
    Identified that the facility failed to report multiple residents testing positive for an infectious disease within the required timeframe. Issued a deficiency for not submitting the incident reports as mandated.
    • § 87705(c)(4)
    27 Jul 2021
    Identified several deficiencies during an unannounced annual inspection, including staff not wearing masks upon arrival, unfinished carpet in the memory care unit, two residents’ bathroom faucets not draining properly, and absence of a carbon monoxide detector, with a civil penalty assessed.
    • § 87303(a)
    • § 87468.1(a)(2)
    • § 1569.311
    27 Jul 2021
    Found multiple safety and health deficiencies, including unstaffed masks, unfinished flooring, drainage issues in bathrooms, and absence of carbon monoxide detection, resulting in a civil penalty.
    23 Apr 2021
    Investigated claim that a resident was denied home health by staff; interviews indicated staff were told to admit only hospice or home health at the start of the pandemic. Found that the Personal Rights allegation was supported by the evidence and could be amended if additional information is received.
    23 Apr 2021
    Found Neglect/Lack of Supervision and Other allegations unsubstantiated after interviews with staff and residents and review of records; staff were trained and residents described them as knowledgeable and helpful.
    23 Apr 2021
    Investigated, interviews with 13 staff and 9 residents did not support the allegation that a staff member was under the influence or smelled of alcohol; only one staff member reported possible intoxication and two noted odd appearance, while the rest denied such observations. No deficiencies were noted.
    23 Apr 2021
    Investigated allegations that staff member appeared under the influence or smelled of alcohol; found no sufficient evidence to support that the violation occurred.
    03 Nov 2020
    Found that preadmission fees were disclosed in the admission agreement and signed by the resident's representative. Found a roof leak in a resident's room during heavy rain.
    03 Nov 2020
    Identified that medications were not administered as prescribed, and that staff administered liquid medications beyond their scope of practice.
    03 Nov 2020
    Identified that a resident’s pre-admission appraisal was not signed and no in-person assessment occurred before move-in. Found that the admissions agreement offered a refund if no pre-admission appraisal was completed, but a proper appraisal prior to admittance was not performed.
    03 Nov 2020
    Found that the facility did not conduct a proper pre-admission assessment of a resident prior to their move-in, violating licensing regulations and the terms of the admissions agreement.
    • § 87468.1(a)(16)
    29 Apr 2020
    Confirmed the facility installed and tested a delayed egress system in a memory care area, allowing for its use with updated licensing.
    • § 87633(j)(1)
    • § 87465(a)(5)
    13 Feb 2020
    Found that the facility used delayed egress without proper authorization and installed a fence blocking fire department access, both of which compromised fire safety.
    • § 87303(a)
    25 Nov 2019
    Investigated an incident involving staff purposefully agitating a resident, resulting in video evidence and the termination of the involved staff members. Confirmed that staff failed to treat the resident with dignity and respect.
    • §
    • §

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