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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206891
Report Date: 12/28/2021
Date Signed: 01/03/2022 03:21:32 PM

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:GARZA-DAVIDSON, SAMANTHAFACILITY TYPE:
740
ADDRESS:4301 BUENA VISTA RDTELEPHONE:
(661) 837-1337
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:128CENSUS: 78DATE:
12/28/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Samantha Davidson Executive Director
Mikayla Arellano, Memory Care Director 		TIME COMPLETED:
06:30 PM
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On 12/28/21, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to conducts interviews with staff members that witnessed a self reported incident in the Memory Care unit.

LPA was greeted at the door by receptionist. COVID19 precautionary measures were taken prior to LPA's entry. LPA toured the Memory Care Unit at the facility with Executive Director and Memory Care Director. LPA stated the purpose of visit was to conduct interviews with the Executive Director and staff that was on duty the evening of the incident that occurred 12/27/2021.

LPA interviewed Executive Director (ED), Memory Care Director (MCD) Staff S1 and Staff S2. LPA obtained contact information for all staff on shift the evening of the incident. LPA obtained verification of detailed staffing logs for 12/27/21.

LPA has requested MCD to provide Physician's Report's (LIC 602a) for all 33 resident's in the Memory Care Unit and to also provide proof required staff training records for all staff working in Memory Care for the months of November and December 2021.


Due to time constraint, LPA will return at a later date to cite deficiencies. Exit interview conducted.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021
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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