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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157204130
Report Date: 07/19/2023
Date Signed: 07/19/2023 01:46:16 PM


Document Has Been Signed on 07/19/2023 01:46 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: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: 29DATE:
07/19/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Irma Langston, Executive DirectorTIME COMPLETED:
01:46 PM
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On 07/19/23, Licensing Program Analyst (LPA) M. Yang arrived at the facility unannounced to conduct a case management visit. LPA met with Executive Director (ED) Irma Langston, introduce self, and stated the purpose of the visit.

The purpose of the visit is to address an incident reported to the department occurred on 06/24/23 where Resident 1 (R1) was noted change of condition. Responsible party arrived at the facility and resident was sent to emergency room. LPA conducted interviews.

No deficiencies issued during visit.

An exit interview was conducted. A copy of this report to ED, whose signature confirms receipt of this report.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2023
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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