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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157204130
Report Date: 01/09/2023
Date Signed: 01/18/2023 03:34:56 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/22/2022 and conducted by Evaluator Mai Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20221222134955
FACILITY NAME:PACIFICA SENIOR LIVING BAKERSFIELDFACILITY NUMBER:
157204130
ADMINISTRATOR:BRADFORD, CASSONDRAFACILITY TYPE:
740
ADDRESS:3209 BOOKSIDE DRTELEPHONE:
(661) 663-9671
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:55CENSUS: 40DATE:
01/09/2023
UNANNOUNCEDTIME BEGAN:
11:38 AM
MET WITH:Irma Langston, Assistant Executive DirectorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility has pests.
INVESTIGATION FINDINGS:
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On 01/09/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct a subsequent complaint visit and delivered finding for the above allegation. LPA met with Irma Langston, Assistant Executive Director (AED) and announced the purpose of the visit.

During the course of the investigation, the Department conducted interviews, toured the facility and reviewed records. Ants were present and observed in residents’ room.

Based on interviews conducted, records reviewed and tour of facility, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 & Chapter 8, is being cited on the attached LIC 9099D.

An exit interview was conduct. A Plan of Correction was discussed with AED. A copy of this report and appeal rights was provided to the AED via email. Report signed on-site.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 24-AS-20221222134955
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PACIFICA SENIOR LIVING BAKERSFIELD
FACILITY NUMBER: 157204130
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/16/2023
Section Cited
CCR
87303(a)
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Maintenance and Operation 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.

This requirement is not met as evidenced by:

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Licensee shall submit written plan to CCL of what preserved measure will be taken to ensure ants are prevented from reoccurring by 1/16/23. In the meantime, a thorough check in all rooms is to be completed with a follow up on weekly basis check.
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Based on records reviewed, interview conducted and tour, the licensee did not comply with the section cited above. LPA and Assistant Executive Director observed lives and dead ants in residents’ room and records shown ants was inspected in residents' room which poses/posed a potential health, safety or personal rights risk to persons 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.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/22/2022 and conducted by Evaluator Mai Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20221222134955

FACILITY NAME:PACIFICA SENIOR LIVING BAKERSFIELDFACILITY NUMBER:
157204130
ADMINISTRATOR:BRADFORD, CASSONDRAFACILITY TYPE:
740
ADDRESS:3209 BOOKSIDE DRTELEPHONE:
(661) 663-9671
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:55CENSUS: 41DATE:
01/09/2023
UNANNOUNCEDTIME BEGAN:
11:38 AM
MET WITH:Irma Langston, Assistant Executive DirectorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
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7
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9
Facility staff yell at residents and did not treat them with respect.
INVESTIGATION FINDINGS:
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On 01/09/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct a subsequent complaint visit and delivered finding for the above allegation. LPA met with Irma Langston, Assistant Executive Director (AED) and announced the purpose of the visit.

During the course of the investigation, the Department conducted interviews with staffs and residents there was insufficient evidence to prove or disprove facility staff yell at residents and did not treat them with respect. Therefore, the above allegation is found to be UNSUBSTANTIATED. Exit interview was conducted. A copy of this report was provided via email to the AED. Report signed on-site.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3