157206891-6-16-2022-24-AS-LSAR-CFFL8K-20220616083204

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 157206891
Report Date: 06/14/2022
Date Signed: 06/16/2022 08:33:12 AM

Document Has Been Signed on 06/16/2022 08:33 AM - 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, THE		FACILITY NUMBER:	157206891
ADMINISTRATOR:	CANO, EDIE		FACILITY TYPE:	740
ADDRESS:	4301 BUENA VISTA RD		TELEPHONE:	(661) 837-1337
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93311
CAPACITY:	128	CENSUS: 77	DATE:	06/14/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Interim Executive Director, Jill Libhart		TIME COMPLETED:	04:30 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 06/14/2022, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to conduct a case management visit based on information received while conducting investigations and records review. LPA was greeted by receptionist and COVID precautionary measures were taken at the time of entry. LPA was met by Interim Executive Director (IED) and toured the Memory Care building.

LPA Salazar received documentation of incidents involving Resident R1 and Resident R2. Records reveal both R1 and R2 have a hired one on one supervision due to ongoing behaviors.

LPA reviewed documented incidents involving physical aggression involving R1 for the following dates: 12/30/21, 04/18/22, 05/02/22, 05/25/22, 06/09/22. These incidents involved (4) other residents in care and multiple staff members.

LPA reviewed documented incidents involving physical aggression involving R2 for the following dates: : 01/24/22, 01/26/22, 02/05/22, 02/06/22, 02/11/22, 02/23/22, where R2 was physically aggressive with other residents in care, care companions and staff.

Based on information received and per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiency is being cited on the attached 809-D.

An exit interview was conducted with Interim Executive Director. A copy of this report and appeal rights were discussed and provided. A plan of correction was developed by IED and reviewed with LPA.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa Salazar	TELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022

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

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: 06/14/2022

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
26
27
28
29
30
31
32

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.

· : Based on today’s visit, a deficiency is being cited, per California Code of Regulations, Title 22, Division 6, Chapter 8 on the attached 809D.

An Immediate Civil Penalty is being assessed in the amount of $1000 for a repeat violation. This violation has a direct and immediate risk to the health, safety, or personal rights of clients in care.

An exit interview was conducted with Interim Executive Director XXXXXXXX. A copy of this report and appeal rights were discussed and provided to XXXXXX. A plan of correction was developed by ED and reviewed with LPA.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa Salazar	TELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3

Document Has Been Signed on 06/16/2022 08:33 AM - 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: 06/14/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/15/2022 Section Cited	1 2 3 4 5 6 7	87455 Acceptance and Retention Limitations (c) No resident shall be accepted or retained if any of the following apply: (3) The resident's primary need for care and supervision results from either: (A) An ongoing behavior, caused by a mental disorder, that would upset the general resident group; This requirement was not met as evidenced by LPAs records review of R1 & R2's LIC602 and LIC624. R1 & R2 require one on one supervision to ensure the safety of residents in care due to continuous and ongoing behaviors. This poses an immediate risk to resident's in care.
	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	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa Salazar	TELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3