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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209136
Report Date: 02/10/2022
Date Signed: 02/10/2022 04:46:07 PM

Document Has Been Signed on 02/10/2022 04:46 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: 36DATE:
02/10/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Anthony BarbatoTIME COMPLETED:
02:20 PM
NARRATIVE
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LPA K. Kaur conducted an unannounced complaint inspection on this day to open the complaint investigation. LPA met with Administrator and stated the purpose of the visit.

During the course of the investigation, LPA reviewed records for R1. The Needs and Services Plan for R1 was incomplete.

Deficiency is being cited based on records review in accordance with the CCR Title 22 on the attached 809-D.



An exit interview was conducted with Licensee Representative Anthony Barbato and a copy of this report with appeal rights will be provided to the licensee via email. A read receipt confirms the Licensee received these documents.
SUPERVISORS NAME: Brenda White
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2022
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 02/10/2022 04:46 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 02/10/2022 at 02:17 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: 02/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/15/2022
Section Cited
CCR
87459(a)

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87459 Functional Capabilities
(a) The facility shall assess the person's need for personal assistance and care by determining his/her ability to perform specified activities of daily living.

This requirement is not met as evidenced by:
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Administrator agreed to complete Needs and Services plan for R1 by POC due date.
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During the course of the investigation, LPA reviewed records for R1. The Needs and Services Plan for R1 was incomplete.
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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: 02/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2022


LIC809 (FAS) - (06/04)
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