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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157204131
Report Date: 07/19/2021
Date Signed: 07/22/2021 05:57:06 PM



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
04/23/2021 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20210423110253
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: DATE:
07/19/2021
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Executive Director, Cassondra BradfordTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff hit resident.
INVESTIGATION FINDINGS:
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On 07/19/20, Licensing Program Analyst (LPA) L. Salazar arrived to the facility unannouced to deliver findings on the above allegation.

During the course of the investigation, LPA conducted interviews and record reviews. Based on interviews and observation of record reviews, S1 stated they "patted R1 on the bottom in a playful manner". The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Deficiencies are being cited in accordance to California Code of Regulations, Title 22, Division 6, see LIC 9099D. Exit interview conducted and appeal rights given.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021
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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Control Number 24-AS-20210423110253
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 MEMORY CARE
FACILITY NUMBER: 157204131
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/19/2021
Section Cited
HSC
1569.269(10)
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Enumerated rights; severability
(a) Residents of residential care facilities for the elderly shall have all of the following rights:(10)To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.
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Executive Director(ED) conducted internal investigation, suspended Staff S1. After investigation, additional staff training for Abuse and Neglect in the Elder Care Setting was conducted on 03/02/21.
*** POC Cleared***
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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: 07/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021
LIC9099 (FAS) - (06/04)
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