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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206770
Report Date: 01/25/2024
Date Signed: 01/26/2024 01:07:19 PM


Document Has Been Signed on 01/26/2024 01:07 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:PERLA PENAFACILITY TYPE:
740
ADDRESS:4501 UPLAND POINT DRIVETELEPHONE:
(661) 447-4800
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93306
CAPACITY:102CENSUS: 60DATE:
01/25/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:22 PM
MET WITH:Administrator Perla PenaTIME COMPLETED:
08:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Shawna Doucette and Miriam Flores conducted a visit to deliver findings and during the course of the investigation deficiencies were found. LPAs met with Administrator Perla Pena.


After conducting interviews and reviewing files, if was found the facility did not call emergency services immediately after R1 fell and obtained a fracture.


If warranted civil penalties will be issued at a later date. Refer to 809D for deficiency.


An exit interview and a copy of this report with plan of correction and appeal rights were provided to the Administrator.

SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024
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 01/26/2024 01:07 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: 01/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/26/2024
Section Cited
CCR
87469(c)(1)

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87469 Advanced Directives and Requests Regarding Resuscitative Measures (c) If a resident who has an advance directive and/or request regarding resuscitative measures form on file experiences a medical emergency, facility staff shall do one of the
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Plan of Correction POC Licensee agrees to submit a written statement of the understanding of the regulation and how it will be met by POC due date 1/26/24.
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following: (3) Specifically for a terminally ill resident that is receiving hospice services and has completed an advance directive and/or request regarding resuscitative measures form pursuant to Health and Safety Code section 1569.73(c), and is experiencing a life-threatening emergency as displayed by symptoms of impending death that is directly related to the expected course of the resident’s terminal illness, the facility may immediately notify the resident’s hospice agency in lieu of calling emergency response (9-1-1). For emergencies not directly related to the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1).
This requirement was not met as evidenced by: Facility did not call 911 after R1 fell and fractured R1's hip which poses an immediate health safety and or personal rights risk to residents 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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2