157209136-4-24-2023-24-AS-KKAR-CR7N2S-20230424100514

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 157209136
Report Date: 04/20/2023
Date Signed: 04/24/2023 10:06:48 AM

Document Has Been Signed on 04/24/2023 10:06 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	REDWOOD SENIOR LIVING BAKERSFIELD		FACILITY NUMBER:	157209136
ADMINISTRATOR:	PONCE, BEATRIZ		FACILITY TYPE:	740
ADDRESS:	810 S UNION AVE		TELEPHONE:	(415) 810-0145
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93307
CAPACITY:	41	CENSUS: 40	DATE:	04/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:23 AM
MET WITH:	Beatriz Ponce, Administrator and Anthony Barbato, Licensee		TIME COMPLETED:	02:00 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 4/20/2023, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by staff. LPA conducted facility tour with Administrator. All pathways, entrances and exits were clear from obstructions. The tour started in the kitchen. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Tour continued to Residents Rooms. LPA toured several bedrooms which were observed to be furnished with required furniture and adequate lighting. Bathrooms were properly equipped with non-slip mats and grab bars. Fire extinguisher in hallway two was last serviced on 8/16/2022 and was fully charged. Closet full of clean linen supply observed. Cleaning supplies and chemicals are kept locked in hallway closet. Medications are kept in 2 locked Med carts in the staff office. At 2 PM LPA reviewed residents medication with MARS and centrally stored list and observed medication was not disturbed to the resident. Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report. Staff files were reviewed for good health. It was verified that there are at least two staff on duty who is CPR certified. LPA observed in the facility front yard sufficient seating and shaded area with trees. Deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6. Continued on next page.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

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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Document Has Been Signed on 04/24/2023 10:06 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: REDWOOD SENIOR LIVING BAKERSFIELD	FACILITY NUMBER: 157209136
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(c)(2)

87465(c)(2) Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 1 when LPA reviewed the residents’ medication with MARS and centrally stored list and observed medication was not disturbed to the resident for 16 consecutive days which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/21/2023
	Plan of Correction
1 2 3 4	AD has agreed to provide training to all staff who assist residents with medication. Training will include the facility documentation procedure. A copy of the training in service sign in and materials used will be provided to CCLD via email or fax. AD has scheduled resident to be taken to doctors to get labs completed and have doctors review missed medication.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: REDWOOD SENIOR LIVING BAKERSFIELD	FACILITY NUMBER: 157209136
	VISIT DATE: 04/20/2023

NARRATIVE

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LPA is requesting the following documents be submitted to the Fresno CCL office by 4/27/2023: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents LIC9020.

An exit interview was conducted with Administrator. Report signed on-site; a copy of this report, 809D with appeal rights was provided. .

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

LIC809 (FAS) - (06/04)

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