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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157204130
Report Date: 01/27/2022
Date Signed: 01/28/2022 08:20:22 AM

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: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: DATE:
01/27/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:TIME COMPLETED:
03:45 PM
NARRATIVE
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On 01/27/2022, Licensing Program Analyst (LPA) arrived at the facility unannounced to conduct a case management visit based on a Trust audit the Department conducted.

Trust Audit Report, dated 6/19/20, the following occurred.

Resident 1 (R1) moved into facility on 2/8/16 and thereafter, R1’s rate was increased on three occasions, the first of which was agreed upon. Thereafter, on 2/1/18 and 2/1/19, facility raised the rate again however these rate increases were not agreed upon when facility did not obtain signatures from R1 and/or R1’s responsible party as required by R1’s Residence and Care Agreement, which states on page 22, “This Agreement (together with the document and appendices referenced herein) constitutes the entire agreement between you and us and may be amended only by a written instrument signed by you and by our authorized representative.” The unagreed upon increases resulted in a refund owed on R1’s behalf in the amount of $6,637.50.



The audit also found that facility charged R1 for tray service for a period of 8 months at a rate of $250 per month without any written acknowledgement, resulting in a refund owed on R1’s behalf in the amount of $2,000.

Deficiencies are being cited in the attached 809-D for violation of Title 22, Division 6, Chapter 8, Section 87507. Appeal Rights given.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022
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
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: PACIFICA SENIOR LIVING BAKERSFIELD
FACILITY NUMBER: 157204130
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2022
Section Cited

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The conditions under which a licensee may increase or change rates shall be specified in the admission agreement, pursuant to Health and Safety Code sections 1569.655 and 1569.657.
This requirement was not met when facility raised R1’s monthly rate on 2/1/18 and 2/1/19 without obtaining the signature of R1 and/or R1’s responsible party. This is a potential risk to residents in care.
Type B
02/28/2022
Section Cited

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A statement acknowledging any additional items and/or services that the resident refused to purchase at the time the admission agreement was signed, which shall be signed and dated by the resident or the resident’s representative, if any, and attached to the admission agreement.
This requirement was not met when facility charged R1 for tray service for a period of 8 months without any written acknowledgement. This is a potential risk to residents 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) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2022
LIC809 (FAS) - (06/04)
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