<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206891
Report Date: 08/16/2022
Date Signed: 08/17/2022 03:10:47 PM

Document Has Been Signed on 08/17/2022 03:10 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:VILLAGE AT SEVEN OAKS ASSISTED LIVING, THEFACILITY NUMBER:
157206891
ADMINISTRATOR:OSORIO, JULIUSFACILITY TYPE:
740
ADDRESS:4301 BUENA VISTA RDTELEPHONE:
6618371337
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 128CENSUS: 75DATE:
08/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:29 AM
MET WITH:Krystal Jenkins, Regional Executive Director SpecialistTIME COMPLETED:
08:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 08/16/2022, Licensing Program Analysts (LPAs) L. Salazar and M. Medina arrived at the facility unannounced to conduct a case management inspection based on several incident reports received.

LPAs were greeted by Regional Executive Director Specialist, stated the purpose of the visit and were allowed entry into the facility. COVID precautionary measures were taken at the time of entry. LPAs toured the Memory care unit and observed residents in care.

On 06/17/2022, LPA visited the facility in regard to a self reported alleged incident. LPA reviewed and obtained copy of Staff S1's file which revealed staff was hired in March of 2022 and does not have the required Dementia training hours per regulation.

On 08/14/2022, LPA received an incident report stating Resident R1 called Resident R2 an obscenity and pushed R2 to the floor. No physical injuries observed.

LPA reviewed Resident R3's file and observed that R3 has had multiple falls, resulting in injury requiring hospitalization. The last incident on 07/23/22 was not reported.

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.

An exit interview was conducted with Regional Executive Director Specialist and a copy of this report was provided. A plan of correction was developed and reviewed with LPA. Appeal rights given.


SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2022
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 3
Document Has Been Signed on 08/17/2022 03:10 PM - It Cannot Be Edited


Created By: Lisa Salazar On 08/16/2022 at 01:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 08/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/17/2022
Section Cited
CCR
87468.1(a)(3)

1
2
3
4
5
6
7
87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3)To be free from punishment, humiliation, intimidation, abuse...
1
2
3
4
5
6
7
Facility will provide documentation evidencing one on one staffing support will be provided and maintained 24/7 to ensure the safety of residents in care by POC date
8
9
10
11
12
13
14
This requirement was not met as evidenced by an incident that occurred with R1 calling R2 an obscenity then pushed R2 to the floor. This poses an immediate risk to residents in care.
8
9
10
11
12
13
14
Type B
08/26/2022
Section Cited
CCR87211(a)(1)(D)

1
2
3
4
5
6
7
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... (D) Any incident which threatens the welfare, safety or health of any resident,...This requirement was not met as evidenced by LPA's records review of R3's file. R3 had a fall on 07/23/22, resulting in injury which was not reported.

1
2
3
4
5
6
7
Faciliy will provide Mandated Reporter Training (SOC341) to all staff members by POC date.

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 Hoffmann
LICENSING EVALUATOR NAME:Lisa Salazar
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/17/2022 03:10 PM - It Cannot Be Edited


Created By: Lisa Salazar On 08/16/2022 at 02:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 08/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/17/2022
Section Cited
CCR
87705(b)(2)

1
2
3
4
5
6
7
87705 Care of Persons with Dementia
(b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials.
1
2
3
4
5
6
7
Memory Care Director removed the aerosol immediately and will provide documentation evidencing staff training will be completed 08/26/22.
8
9
10
11
12
13
14
This requirement was not met as evidenced by LPA's observation of furniture polish aerosol located in R3's room which poses an immediate risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 Hoffmann
LICENSING EVALUATOR NAME:Lisa Salazar
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2022


LIC809 (FAS) - (06/04)
Page: 3 of 3