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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209136
Report Date: 11/04/2021
Date Signed: 11/04/2021 03:33:19 PM

Document Has Been Signed on 11/04/2021 03:33 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:REDWOOD SENIOR LIVING BAKERSFIELDFACILITY NUMBER:
157209136
ADMINISTRATOR:ESPINAL, KENNYFACILITY TYPE:
740
ADDRESS:810 S UNION AVETELEPHONE:
(415) 810-0145
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93307
CAPACITY: 41CENSUS: 38DATE:
11/04/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:34 PM
MET WITH:Licensee, Anthony BarbatoTIME COMPLETED:
02:59 PM
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Licensing Program Analyst (LPA) Darius Williams conducted a facility visit in response to information on Resident 1’s (R1) physician report. LPA Williams met with Licensee Anthony Barbato and discussed the purpose of the visit.

LPA Williams conducted record reviews.

R1 was admitted to the facility on 4/16/2021. According to R1’s physician report, dated 4/13/2021, R1 required total assistance with all activities of daily living, which is a prohibited health condition.

R1’s hospice services was initiated until 5/21/2021.

Based on record reviews, the Licensee admitted and retained R1 with a prohibited health condition (residents who depends on others to perform all activities of daily living), between 4/16/2021 and 5/21/2021. Title 22, Division 6, Chapter 8, Article 11, Section 87615(a)(5), is being cited on the attached LIC 9099D.

LPA Williams discussed plan of correction with Licensee.

A copy of this report and appeal rights were provided.

SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2021
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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Document Has Been Signed on 11/04/2021 03:33 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Darius Williams On 11/04/2021 at 03:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: REDWOOD SENIOR LIVING BAKERSFIELD
FACILITY NUMBER: 157209136

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
11/08/2021
Section Cited
CCR
87615(a)(5)

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87615 Prohibited Health Conditions. (a) Persons who require health services...those specified below shall not be admitted or retained..., (5) Residents who depend on others to perform all activities of daily living...

This requirement was not met evident by:
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Resident 1 no longer resides at the facility.

Licensee has agreed to review Sections 87611 through 87617 regarding health restrictions. Licensee will submit document acknowleding reading and understanding of the regulations to the Department by Plan Of Correction due date of 11/8/2021.
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Based on record reviews, the Licensee did not ensure an exception was obtained prior to accepting Resident 1 who had a prohibited health condition, which poses a potential health and safety risk to persons 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:Serigy Pidgirny
LICENSING EVALUATOR NAME:Darius Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2021


LIC809 (FAS) - (06/04)
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