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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206891
Report Date: 08/09/2022
Date Signed: 08/22/2022 03:42:10 PM


Document Has Been Signed on 08/22/2022 03:42 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/22/2022 10:32 AM

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

NARRATIVE
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On 08/09/22, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to conduct a case management visit based on records review of incident reports submitted and previous facility visits. LPA was greeted by Regional Operations Specialist and Executive Director Specialist, stated the purpose of the visit and was allowed entry into the facility. COVID precautionary measures were taken at the time of entry.

LPA toured the Memory Care unit of the facility and observed residents in care having lunch and social activities together. The facility's current census is 38 in the Assisted Living building and 35 in the Memory Care building.

LPA toured the Memory Care unit of the facility and requested to review of the following records: Copies of LIC 9182 (transfer of a criminal background clearance transfer form) for 10 staff members , complete staff schedules for the months of July 2022 and August 2022, Staff roster, Roster of Residents in care, roster of residents receiving Hospice Care services and Home Health Services that including individual care plans.

A review of facility staff schedule and facility personnel roster show that Staff S1, Staff S5, Staff S6, Staff S9 and Staff S10 do not have criminal background clearance transfers.

On 07/27/2022, an self reported incident was received for Resident R1, R2 & R3 who eloped from the memory care unit and were observed walking outside in the parking lot. Memory Care Director (MCD) observed the residents in care through the window and immediately redirected them back into the facility. No injuries were observed.

(Continued on 809-C)
SUPERVISOR'S NAME: Brenda WhiteTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Melinda HoffmannTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/27/2022 04:35 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/22/2022 01:16 PM

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: VILLAGE AT SEVEN OAKS ASSISTED LIVING, THE
FACILITY NUMBER: 157206891

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/09/2022
Section Cited

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or
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This requirement was not met as evidenced by LPA's review of deparment facility personnel report summary. LPA observed five staff that did not have transfers for crimianl record clearance. This poses an immediate risk to resident's in care. An immediate Civil Penalty of $2500 is hereby assessed.
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Type A
08/10/2022
Section Cited

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities(a)...Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.

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This requirement was not met as evidenced by R1, R2 and R3 exiting the memory care building without staff knowledge and were found in the facility parking lot by Memory Care Director. This poses an immediate risk to resident's in care. An immediate Civil Penalty in the amount of $500 is hereby assessed.
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**POC cleared**
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) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


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: VILLAGE AT SEVEN OAKS ASSISTED LIVING, THE
FACILITY NUMBER: 157206891
VISIT DATE: 08/09/2022
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(Continued from 809)

On 07/27/2022, an self reported incident was received for Resident R1, R2 & R3 who eloped from the memory care unit and were observed walking outside in the parking lot. Memory Care Director (MCD) observed the residents in care through the window and immediately redirected them back into the facility. No injuries were observed.

Based on today’s visit, per California Code of Regulations, Title 22, Division 6, Chapter 8 deficiencies are being cited on the attached 809 D. All violations if not corrected will have a direct and immediate risk to the health, safety, or personal rights of residents in care.

Immediate Civil Penalties are being assessed in the amount of $2500 for Criminal Background clearance transfers and $500 for lack of care and supervision Exit interview conducted with Regional Executive Director Specialist and a copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
LIC809 (FAS) - (06/04)
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