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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157204131
Report Date: 10/14/2020
Date Signed: 10/14/2020 02:15:15 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
01/17/2020 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20200117113437
FACILITY NAME:PACIFICA SENIOR LIVING BAKERSFIELD MEMORY CAREFACILITY NUMBER:
157204131
ADMINISTRATOR:BRADFORD, CASSONDRAFACILITY TYPE:
740
ADDRESS:3115 BROOKSIDE DRTELEPHONE:
(661) 663-9671
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:40CENSUS: 38DATE:
10/14/2020
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Cassondra Bradford, Executive Director TIME COMPLETED:
03:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained multiple falls while in care.
Staff do not safeguard resident's personal items.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/14/2020, Licensing Program Analyst (LPA), L. Salazar, contacted Executive Director Cassondra Bradford to deliver findings on the above allegations. Due to COVID-19 and precautionary measures, this visit was conducted via tele inspection.

During the course of the investigation, LPA conducted record reviews, interviews with Reporting Party (RP) and Staff. LPA did not interview residents due to cognitive status. LPA conducted a physical tour of the facility when complaint was opened.

Record Reviews and physical plant inspection revealed Resident R1's health has begun to decline and did have an increase in falls. LPA reviewed the incident reports that were submitted by facility for R1. Based on the information received, the allegations are UNSUSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
01/17/2020 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20200117113437

FACILITY NAME:PACIFICA SENIOR LIVING BAKERSFIELD MEMORY CAREFACILITY NUMBER:
157204131
ADMINISTRATOR:BRADFORD, CASSONDRAFACILITY TYPE:
740
ADDRESS:3115 BROOKSIDE DRTELEPHONE:
(661) 663-9671
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:40CENSUS: 38DATE:
10/14/2020
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Cassondra Bradford, Executive Director TIME COMPLETED:
03:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident is not adequately fed.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/14/2020, Licensing Program Analyst (LPA), L. Salazar, contacted Executive Director, Cassondra Bradford to deliver findings on the above allegations. Due to COVID-19 and precautionary measures, this visit was conducted via tele inspection.

During the course of the investigation, LPA conducted record reviews, interviews with Reporting Party (RP), Staff, neither which revealed that Resident R1 was not adequately fed. R1's health has began to decline. Dr. put R1 on a Pureed diet. (see file) LPA did not interview resident due to cognitive status. LPA conducted a physical tour of the facility when complaint was opened. Based on the information received, the allegation is UNFOUNDED.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2