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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157204131
Report Date: 04/25/2024
Date Signed: 04/25/2024 01:02:09 PM


Document Has Been Signed on 04/25/2024 01:02 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) 663-9671
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:40CENSUS: 19DATE:
04/25/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Kelly Porter, Memory Care DirectorTIME COMPLETED:
01:00 PM
NARRATIVE
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On 04/25/24, Licensing Program Analyst (LPA) M. Yang arrived to conduct an unannounced initial complaint investigation and met with Memory Care Director Kelly Porter. LPA toured the facility and conducted interviews.

During the course of the investigation, LPA observed knives and cleaning chemicals stored in kitchen unlocked.

Deficiency is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22,
Division 6.

An exit interview was conduct. An exit interview was conducted, and a copy of this report and appeal rights was provided to the Memory Care Director, whose signature confirms received of this report.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
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 04/25/2024 01:02 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: 04/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/26/2024
Section Cited
CCR
87705(f)(1)

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The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
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Maintenance staff immediately repaired the kitchen door. POC cleared during visit.
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Based on observation, the licensee did not comply with the section cited above when LPA, Memory Care Director, and Maintenance staff observed kitchen door in disrepair and unlock. Residents were present in the dining area when knives and cleaning chemicals were unlocked in the kitchen accessible to residents in care this poses an immediate health, safety or personal rights risk to persons 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: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
LIC809 (FAS) - (06/04)
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