157204130-7-19-2023-24-AS-MYAG-CTVSBJ-20230719134401

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 157204130
Report Date: 07/19/2023
Date Signed: 07/19/2023 01:44:34 PM

Document Has Been Signed on 07/19/2023 01:44 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 BAKERSFIELD		FACILITY NUMBER:	157204130
ADMINISTRATOR:	BRADFORD, CASSONDRA		FACILITY TYPE:	740
ADDRESS:	3209 BOOKSIDE DR		TELEPHONE:	(661) 663-9671
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93311
CAPACITY:	55	CENSUS: 29	DATE:	07/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Irma Langston, Executive Director		TIME COMPLETED:	01:31 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	On 07/19/23, Licensing Program Analyst (LPA) M. Yang arrived at the facility unannounced to conduct Required Annual Inspection. LPA was greeted by receptionist and stated the purpose of the visit. LPA met with Executive Director (ED) Irma Langston and Memory Care Director Don Marchel. LPA conducted tour of facility with ED. Residents were observed walking around the facility and in common areas. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards. Fire extinguisher was observed with a service date of:12/14/22. Last fire drill completed on 06/15/23. Common area and Kitchen was toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in walk-in freezer, walk-in refrigerator, and pantry. Food is delivered twice a week. Refrigerator temperature was maintained at 37 degree F. and freezer was maintained at -7 degree F. LPA toured a sample of resident bedrooms. Residents' rooms were toured and observed with adequately furnished with bed, dresser, and adequate lighting. Hot water temperature tested at between 108.7 degrees F. to 108.9 degrees F. LPA observed securely fastened grab bars and non-skid mat in all shower areas. Medications were stored in a locked medication room in a medication cart. MARs and medications were reviewed. First Aid Kit was stored in medication room and observed with all required items. Adequate PPE supplies was observed. LPA toured activity room and laundry room. Facility courtyard was toured and observed to be free from debris. There was outdoor seating available for the residents.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 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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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: PACIFICA SENIOR LIVING BAKERSFIELD	FACILITY NUMBER: 157204130
	VISIT DATE: 07/19/2023

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A sample of residents’ file was reviewed to have updated emergency contact, Admission agreement, Needs and Services Plan and Pre-Appraisal Plan. A sample of staff files were reviewed. Staff files were observed to have current First Aid/CPR, Health screening, and Personnel record. Staff are fingerprinted clear and associated to the facility.

No deficiencies issued during this inspection.

An exit interview was conducted with the ED. The following documents are requested and submitted to Fresno CCL by: 07/25/23. The following updated forms were requested: Lic 400, Lic 610E, Lic 9282, current Administrator certificate, updated facility sketch, and current liability insurance. A copy of this report was given to the ED, whose signature on this form confirm receipt of these reports.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 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

LIC809 (FAS) - (06/04)

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