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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 155801189
Report Date: 10/28/2022
Date Signed: 10/28/2022 03:49:46 PM


Document Has Been Signed on 10/28/2022 03:49 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:WESTCHESTER GARDENSFACILITY NUMBER:
155801189
ADMINISTRATOR:ROBINSON, SHERVETAFACILITY TYPE:
740
ADDRESS:2228 TRUXTUN AVETELEPHONE:
(661) 324-3091
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93301
CAPACITY:36CENSUS: 16DATE:
10/28/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:46 PM
MET WITH:Administrator, Sherveta RobinsonTIME COMPLETED:
04:01 PM
NARRATIVE
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On 10/28/22 Licensing Program Analyst (LPA) M. Garza arrived at facility to complete an unannounced complaint visit. LPA met with Administrator, Sherveta Robinson and was not COVID pre-screened upon entry into the facility. LPA discussed reason for visit and completed a health and safety check on residents in care.

During complaint investigation a case management was needed. It was found the facility accepted a resident on respite care from the hospital who required a higher level of care. The resident remained at the facility for longer than 14 days. From the period of 8/26/22 through 10/3/22 resident resided at facility.

Deficiencies cited on LIC 809D per Title 22.

An exit interview was completed with Administrator, Sherveta. A copy of this report and appeal rights were given.

SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2022
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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Document Has Been Signed on 10/28/2022 03:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: WESTCHESTER GARDENS
FACILITY NUMBER: 155801189

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/11/2022
Section Cited

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ยง1569.72 Residents requiring skilled nursing or intermediate care; bedridden residents (a) Except as otherwise provided in subdivision (d), no resident shall be admitted or retained in a residential care facility for the elderly if any of the following apply:...
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This requirement was not met as evidence by: review of records and interviews. LPA found facility accepted a resident on respite care who required a higher level of care. The resident remained at the facility for longer than 14 days.
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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.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2022
LIC809 (FAS) - (06/04)
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