157204130-5-4-2022-24-AS-MHON-CE9MUT-20220509095538

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 157204130
Report Date: 05/04/2022
Date Signed: 05/04/2022 12:48:12 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
01/20/2022 and conducted by Evaluator Lisa Salazar

COMPLAINT CONTROL NUMBER: 24-AS-20220120152006

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: 39	DATE:	05/04/2022
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Cassondra Bradford, Executive Director,		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Resident's authorized person was not refunded according to the Admission Agreement

INVESTIGATION FINDINGS:

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On 05/03/2022, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to deliver findings on the above allegation. LPA was greeted by Executive Director and allowed entry into the facility. COVID precautionary measures were taken.

During the investigation, LPA conducted interviews and reviewed records. Interviews with reporting party, and staff reveal a refund was given to the Estate of R1 on 12/29/21. Per the admission agreement, facility should have issued the refund within 15 days of R1's removal of personal belongings from the facility.

Based on the LPA's records review and interviews, the preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D.

An exit interview was conducted and appeal rights given.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa Salazar	TELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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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
01/20/2022 and conducted by Evaluator Lisa Salazar

COMPLAINT CONTROL NUMBER: 24-AS-20220120152006

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: 39	DATE:	05/04/2022
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Executive Director, Cassondra Bradford		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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8
9

Staff did not return resident's durable medical equipment in a timely manner

INVESTIGATION FINDINGS:

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On 05/03/2022, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to deliver findings on the above allegation. LPA was greeted by Executive Director and allowed entry into the facility.

During the investigation, LPA conducted interviews and reviewed records. Interviews with reporting party, and staff reveal the durable equipment was ordered by Resident R1's primary treater and was delivered to the facility for R1.

LPA reviewed R1’s admission agreement and did not observe language to indicate that it is facility’s responsibility to return durable medical equipment (DME) and the DME was not listed on R1’s personal property inventory list (LIC 621). Facility does not order DME; it is ordered by resident physicians. The facility did however, in good faith, refund the estate of R1 for the number of days the DME remained in R1’s room.

Based on the above, the allegation that facility did not return resident’s DME in a timely manner is Unfounded; meaning it was false, could not have happened or is without reasonable basis; we have therefore dismissed the complaint.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa Salazar	TELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

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

Control Number 24-AS-20220120152006

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: 05/04/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/13/2022 Section Cited CCR 87507(f)	1 2 3 4 5 6 7	87507 Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments.	1 2 3 4 5 6 7	Facility refunded the Estate of Resident R1 on 12/29/21. Facility has provided a copy of the move out form ensure reimbursements are made will submit a plan to ensure residents that move out of the facility, will be taken off automatic payments at the time of move out. POC cleared
	8 9 10 11 12 13 14	This requirement was not met as evidenced by LPAs observation of records review and interviews. facility should have issued the refund within 15 days of R1's removal of personal belongings from the facility.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Hoffmann	TELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa Salazar	TELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

LIC9099 (FAS) - (06/04)

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