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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157204131
Report Date: 07/09/2024
Date Signed: 07/09/2024 04:23:34 PM


Document Has Been Signed on 07/09/2024 04:23 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 MEMORY CAREFACILITY NUMBER:
157204131
ADMINISTRATOR:BRADFORD, CASSONDRAFACILITY TYPE:
740
ADDRESS:3115 BROOKSIDE DRTELEPHONE:
(661) 862-9777
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:40CENSUS: 21DATE:
07/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:08 PM
MET WITH:Administrator Angela OhanianTIME COMPLETED:
04:35 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 with Administrator (A1) Angela Ohanian and Memory Care Director Kellie Porter. LPA toured facility with A1.

Residents were observed seating in common areas. 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. 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 a sample of resident bedrooms and was observed to have the required furnishings and with adequate lightening.

Medications were stored in a locked medication room in a medication cart. MARs were reviewed and medications were audit. LPA toured kitchen. All meals are prepared at Assisted Living facility and transferred to facility by staff during mealtime. Bedrooms have Bathrooms hot water temperature was tested and within range between 111.5 to 118.2. LPA observed securely fastened grab bars and non-skid surfaces/mat in shower. A sample of resident and staff files were reviewed to have all the required documents.

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, and currently liability insurance. 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)
Page: 1 of 2


Document Has Been Signed on 07/09/2024 04:23 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 MEMORY CARE
FACILITY NUMBER: 157204131

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on records review, and observation, R1’s MARs were reviewed, and medications were audit and shown that staff did not administer medications as directed by physician, which poses an immediate health and safety risk for the person in care.
POC Due Date: 07/10/2024
Plan of Correction
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Licensee shall submit document of steps the facility will take to ensure facility meets the regulation include ensure staff are administering medications as directed by physician to Fresno CCL office by POC due date 07/10/24.
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)
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