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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209136
Report Date: 12/03/2021
Date Signed: 12/03/2021 11:48:39 AM

Document Has Been Signed on 12/03/2021 11:48 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: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: 34DATE:
12/03/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Licensee Representative Anthony BarbatoTIME COMPLETED:
12:00 PM
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Licensing Program Analysts LPAs K.Kaur and S. Doucette conducted a Case Management to follow up on incidents that occurred on 11/21/21 . LPA was met by Staff Barbara Martin and discussed the purpose of the visit. LPAs and Licensee representative Anthony Barbato began the tour at the front entrance/office of the facility.

Upon entrance of the facility LPAs smelt a strong odor of urine.

Regarding incident facility contacted hospice nurse to notify of R1's medical condition. Facility did not submit incident report within the 7 days.

Deficiencies are being cited based on LPA's observation, interviews conducted, and record review in accordance with the CCR Title 22. See LIC 809D.

An exit interview was conducted with Licensee Representative Anthony Barbato and a copy of this report with Plans of Corrections and appeal rights was provided.
SUPERVISORS NAME: Brenda White
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2021
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 12/03/2021 11:48 AM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Kamaldeep Kaur On 12/03/2021 at 11:20 AM
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: 12/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
12/17/2021
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation, (a) The facility shall be clean, safe, sanitary and in good repair at all times...

This requirement was not met evident by:
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Plan of correction POC Licensee agrees to ensure facility is free of urine odor by POC due date 12/17/2021. LPA will return to facility to ensure POC was completed.
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Based on observation, the Licensee did not ensure the facility was free of urine odor which poses a potential health and safety risks to persons in care.
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Under Appeal
Type B
12/03/2021
Section Cited
CCR87211(a)

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven
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Plan of correction POC Licensee agrees to submit in writing understanding of this regulation by POC due date.
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days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
This requirement was not met evident by: Based on observation of documentation licensee did not submit report within 7 days which poses a potential health and safety risks 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:Brenda White
LICENSING EVALUATOR NAME:Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2021


LIC809 (FAS) - (06/04)
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