<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157203395
Report Date: 01/25/2023
Date Signed: 01/25/2023 02:26:40 PM


Document Has Been Signed on 01/25/2023 02:26 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:BROOKDALE RIVERWALKFACILITY NUMBER:
157203395
ADMINISTRATOR:WEBSTER, REGFACILITY TYPE:
741
ADDRESS:350 CALLOWAY DRTELEPHONE:
(661) 587-0221
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY:376CENSUS: DATE:
01/25/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Martha Fernandez de HobanTIME COMPLETED:
02:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) M. Medina conducted an unannounced Case Management visit regarding a self reported medication error that was received in Fresno Regional Office (RO) on 12/02/22. LPA met with Martha Fernandez de Hoban, Health and Wellness Director during today's visit.

Per incident report, on 11/26/22, R1 received the incorrect dosage of medication. R1 was administered .5 mg of Lorazepam, physician order is .25 mg every 2 hours as needed.

Health & Wellness Director contacted R1’s Physician, Hospice Agency and responsible party.

LPA informed that staff received additional medication training on 11/29/22. LPA reviewed and received copies of MARS and training records.

Deficiency cited on the attached 809D

Exit interview conducted. Appeal rights given.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2023
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 2


Document Has Been Signed on 01/25/2023 02:26 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: BROOKDALE RIVERWALK
FACILITY NUMBER: 157203395

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/26/2023
Section Cited

1
2
3
4
5
6
7
Incidental Medical and Dental Care: (2) Once ordered by the physician the medication is given according to the physician's directions. **This was not met as evidenced by, on 12/02/22 facility self reported to
1
2
3
4
5
6
7
Facility conducted Medication Training for S1 on 11/29/22. Copies of training documents received during Case Management visit.
**DEFICIENCY CLEARED AT TIME OF VISIT
8
9
10
11
12
13
14
Fresno RO medication error for R1 which occurred on 11/26/22.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Melinda HoffmannTELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2