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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157206891
Report Date: 02/22/2022
Date Signed: 03/29/2022 11:31:13 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/23/2021 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20211123112944
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: DATE:
02/22/2022
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Executive Director, Samantha Davidson TIME COMPLETED:
03:56 PM
ALLEGATION(S):
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Resident physically assaulted by another resident resulting in an injury.
INVESTIGATION FINDINGS:
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On 02/22/2022, Licensing Program Analyst (LPA), L. Salazar arrived at the facility unannounced to deliver findings on the above allegation. LPA was greeted by Executive Director, explained the purpose of the visit, and was allowed entry into the facility. COVID precautionary measures were taken at the time of entry.

During the investigation, LPA interviewed staff, Executive Director (ED), Memory Care Director (MCD), Reporting Party (RP) and Hospice Staff (HS). LPA obtained and reviewed facility records, medical records from hospital and from Hospice agency. Interviews and records review reveal facility did not call 911 or seek medical treatment for resident in care.

(continued on 9099-C)

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 24-AS-20211123112944
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/22/2022
NARRATIVE
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Facility records show 4 staff were on duty to supervise 36 residents in the Memory Care unit. One Staff S3 was on break during the incident which only left Staff S1 and Staff S2 on duty the evening of the incident. Interviews with staff revealed the incident happened between 8:30 PM - 9:00 PM, however, the initial altercation was unwitnessed until after the assault happened. S1 was able to pry Resident R2’s hands off of Resident R1 to break up the altercation.

Hospice records reveal, emergency respite care was sought by RP two days after the incident. Resident R1 was taken to the hospital by RP, five days after the incident occurred. The visit was categorized as an assault with bruising to the face, neck, arms and chest. It was noted that the assault was over 5 days ago. R1 had not yet been evaluated by medical staff.

Based on the information received, the Allegation is substantiated. The facility did not provide care and supervision which resulted in injury to R1. Facility did not call 9-1-1 after the resident's assault which poses an immediate Health, Safety and/or Personal Rights risk to residents in care. Deficiencies are being cited on the attached 9099-D.

Pursuant to Health & Safety Code section 1569.49(c)(1), an immediate civil penalty of $500 is assessed. The issuance of additional civil penalties is pending and currently under review. The details of additional civil penalties will be outlined in a future report to the facility, if any.

Exit Interview conducted with Executive Director. Plans of corrections were reviewed and developed. Appeal rights were given to Executive Director.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20211123112944
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/23/2022
Section Cited
CCR
87468.1(a)(3)
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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, or other actions...This requirement was not met as evidenced by LPA's interviews with Staff, Reporting party, Hospice nurses and Executive Director. LPA observed medical records and obtained pictures of R1's injuries. This poses an immediate risk to residents in care.
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Executive Director (ED) has implemented a staff/resident ratio of 1:9. Residents with higher acuity have been relocated to other apartments in the building in efforts to balance the care needs of all residents. All staff will be retrained in CCR, Title 22 Personal Rights regulation provided to ED. ED will send proof of staff signatures acknowledging they have read and understood the regulation by POC date.
Type A
02/23/2022
Section Cited
CCR
87465(g)
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87465 Incidental Medical and Dental Care
(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis...This requirement was not met as evidenced by medical records and LPA's interviews. 911 was not called and medical attention was not received for R1 until 5 days after the incident. Medical treatment and police reporting was initiated by family of the resident. This poses an immediate risk to resident's in care. An immediate civil penalty of $500 is hereby assessed.
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Executive Director has added additional staffing to the Memory Care unit. There are now five staff members on the AM/PM shift in lieu of four. Staff has been retrained to call for immediate medical assistance/treatment for any unwitnessed injuries observed. Skin assessments are done twice a week, reviewed by an LVN weekly. Follow up report is sent to the clinical specialist at corporate office. Executive Director conducted emergency medical training for all staff. ED will send proof of training.
Type A
CCR
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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: 02/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3