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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206891
Report Date: 03/14/2022
Date Signed: 03/15/2022 09:42:46 PM


Document Has Been Signed on 03/15/2022 09:42 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:GARZA-DAVIDSON, SAMANTHAFACILITY TYPE:
740
ADDRESS:4301 BUENA VISTA RDTELEPHONE:
(661) 837-1337
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:128CENSUS: 80DATE:
03/14/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Executive Director, Samantha Davidson, TIME COMPLETED:
04:00 PM
NARRATIVE
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On 03/14/22, Licensing Program Analysts (LPAs') L. Salazar and L. Cabrera arrived at the facility unannounced to conduct a case management inspection. The inspection is based on interviews and records review while conducting an investigation on complaint #24-AS-20211123112944. LPAs' were greeted by receptionist, stated the purpose of their visit and were allowed entry into the facility.

During the investigation, LPA Salazar conducted records review that revealed, facility did not complete a pre-admission appraisal to determine Resident R2's suitability. Facility accepted and retained R2 without observing the physician's report (LIC 602) documenting R2 has inappropriate and aggressive behaviors.

The facility did not report physical abuse, that resulted in injury, to licensing, Long Term Care Ombudsman (LTCO) or law enforcement as required. ED submitted incident report (LIC624) a day after incident occurred.

Administrator stated they were not aware the facility was supposed to call 911 or seek medical treatment if resident's are on Hospice.

LPA Salazar has reviewed documentation and conducted interviews with staff. Based on information received and per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 809-D.

Exit Interview conducted with ED. A plan of correction was reviewed and appeal rights given.


SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022
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 03/15/2022 09:42 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: VILLAGE AT SEVEN OAKS ASSISTED LIVING, THE
FACILITY NUMBER: 157206891

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/15/2022
Section Cited

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87211 Reporting Requirements
(b) Any suspected physical abuse that results in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within two (2) hours as required by Welfare and Institutions Code Section 15630(b)(1).
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This requirement was not met as evidenced by LPAs observation of incident report (LIC 624) that was submitted the following day. 11/16/21.
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Type A
03/15/2022
Section Cited

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87461 Mental Condition
(a) The facility shall determine the amount of supervision necessary by assessing the mental status of the prospective resident to determine if the individual: (5) has a documented history of behaviors which may result in harm to self or others.
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This requirement was not met as evidenced by LPAs interview and records review that revealed the facility was not aware of any aggressive condition R2 had. This violation poses an immediate risk to the health, safety, or personal rights of clients 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: Melinda HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 03/15/2022 09:42 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: VILLAGE AT SEVEN OAKS ASSISTED LIVING, THE
FACILITY NUMBER: 157206891

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/15/2022
Section Cited

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87405 Administrator - Qualifications and Duties
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.(1) Knowledge of the requirements for providing care and supervision appropriate to the residents.
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This requirement was not met as evidenced by ED did not call 911 or seek medical attention for R1. This violation poses an immediate risk to the health, safety, or personal rights of clients in care.

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Type B
03/28/2022
Section Cited

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87457 Pre-Admission Appraisal - General
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.(1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462 Social Factors.
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This requirement was not met as evidenced by LPAs observation of the LIC 603 (Preplacement Appraisal information). Page one was not completed. This violation has a potential risk to the health, safety, or personal rights of clients 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: Melinda HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3