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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157204130
Report Date: 07/09/2024
Date Signed: 07/09/2024 02:08:04 PM


Document Has Been Signed on 07/09/2024 02:08 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:OHANIAN, ANGELAFACILITY TYPE:
740
ADDRESS:3209 BOOKSIDE DRTELEPHONE:
(661) 663-9671
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:55CENSUS: 25DATE:
07/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Angela Ohanian, AdministratorTIME COMPLETED:
02:08 PM
NARRATIVE
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On 07/09/24, Licensing Program Analyst (LPA) M. Yang arrived at the facility unannounced to conduct the Annual Inspection. LPA met and toured facility with Administrator (A1) Angela Ohanian.

Facility has sufficient furnishings inside and outside for resident use. The facility was observed to be at a comfortable temperature, clean, and no passageway obstructions or fire hazards. Residents were observed seating in common areas. Facility is equipped with pull stations and fire sprinklers throughout facility. Fire extinguisher was observed throughout the facility with a service date of: 09/15/2023.

LPA toured kitchen. An adequate supply of perishable and non-perishable food was observed to be properly stored in freezer, refrigerator, and pantry. Temperature for refrigerator observed maintained at 40 degrees F and freezer maintained at -7 degrees F. LPA and Administrator observed janitor cart with cleaning chemicals unlock set aside in hall between the receptionist desks and facility bathroom. LPA observed exits to have a 15-second delay egress. Chemicals stored and locked in house keeping’s room. LPA toured a sample of resident bedrooms. LPA observed medications and tools unlock in resident’s room. Bathrooms hot water temperature was tested and within range between 109.6 to 113.3 degrees F. LPA observed securely fastened grab bars and non-skid surfaces in shower. A sample of resident and staff files were reviewed to have all the required documents. Medications were stored in a locked medication room in a medication cart. MARs and medications were reviewed.

A deficiency is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title
22, Division 6. Exit interview was conducted.

The following documents are requested and submitted to Fresno CCL by: 07/15/24. The following updated forms were requested: Lic 308, Lic 500, Lic 610E. A copy of this report and appeal rights was provided to Administrator.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024
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 07/09/2024 02:08 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: PACIFICA SENIOR LIVING BAKERSFIELD
FACILITY NUMBER: 157204130

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when LPA and A1 observed janitor cart with cleaning chemicals unlock set aside in hall between the receptionist desks and facility bathroom. LPA and A1 observed two tool sets with box cutter stored in room 106 unlock. LPA and A1 observed a knife and sharp from blinder stored in room 107’s kitchen unlocked accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2024
Plan of Correction
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Staff immediately removed janitor’s cart. Administrator immediately removed sharps, and tool sets to a lock room. POC cleared during visit.
Type A
Section Cited
CCR
87465(h)(2)
Centrally stored medicines shall be kept in a safe and locked place... not accessible to persons other than employees...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when LPA and A1 observed a medication on top of resident’s nightstand in room 107 unlocked accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2024
Plan of Correction
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Administrator immediately removed and locked the medication bottle in the medication room. POC cleared during visit.
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) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 07/09/2024 02:08 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: PACIFICA SENIOR LIVING BAKERSFIELD
FACILITY NUMBER: 157204130

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when LPA observed mold inside facility’s ice machine which poses a potential health, safety or personal rights risk to person in care.
POC Due Date: 07/15/2024
Plan of Correction
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Ice machine was cleaned immediately. POC cleared during visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4