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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206770
Report Date: 04/12/2023
Date Signed: 04/12/2023 06:56:24 PM


Document Has Been Signed on 04/12/2023 06:56 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:POINTE AT SUMMIT HILLS, THEFACILITY NUMBER:
157206770
ADMINISTRATOR:BENNY FARILLASFACILITY TYPE:
740
ADDRESS:4501 UPLAND POINT DRIVETELEPHONE:
(661) 447-4800
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93306
CAPACITY:102CENSUS: 56DATE:
04/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Assistant Administrator Sheree Addison and Administrator Griselda "Gracie" RamirezTIME COMPLETED:
07:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to conduct the Required Annual Inspection. LPA met with Assistant Administrator Sheree Addison and Administrator Griselda "Gracie" Ramirez. LPA disclosed the purpose of the inspection and was granted entry into the facility by the Administrator.

A tour of the facility was conducted with the Administrator and Assistant Administrator.

LPA Doucette observed 6 resident apartments. Residents' rooms were toured and inspected. Hot water temperature was measured from 115.3 to 119.5 F. Residents were observed to be participating in activities.

Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. Medications were stored in a locked Medication cart and in a locked medication room. Cleaning supplies were in a locked storage closet. Facility has a pull station fire alarm and a fire panel. Fire extinguishers were charged and had service dates of 5/05/22.

There was outdoor seating for the residents.

Resident, medication and staff records were reviewed. C1 had a medication error on 3/31/23 and 04/11/23. Current first aid and CPR were on file for staff. Annual training needs to be updated for staff.

See attached 809D.

An exit interview was conducted with the Assistant Administrator. A copy of this report, plan of correction and appeal rights were provided.

SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2023
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 4


Document Has Been Signed on 04/12/2023 06:56 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: POINTE AT SUMMIT HILLS, THE
FACILITY NUMBER: 157206770

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review and interviews, the licensee did not comply with the section cited above by missing C1's medication, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/13/2023
Plan of Correction
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Plan of Correction POC Licensee agrees to train medication techinician staff in administering and logging medications by POC due date 5/8/23.
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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 04/12/2023 06:56 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: POINTE AT SUMMIT HILLS, THE
FACILITY NUMBER: 157206770

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interviews, the licensee did not comply with the section cited above in several staff not being up to date with training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2023
Plan of Correction
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Plan of Correction POC Licensee agrees to complete the 20 hours of annual training for all staff by POC due date 5/12/23.
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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4