157209257-1-24-2024-24-AS-MYAG-CZSMTM-20240124085342

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 157209257
Report Date: 01/23/2024
Date Signed: 01/24/2024 08:54:36 AM

Document Has Been Signed on 01/24/2024 08:54 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:	IVY PARK AT SEVEN OAKS		FACILITY NUMBER:	157209257
ADMINISTRATOR:	BRADLEY, PAMELA		FACILITY TYPE:	740
ADDRESS:	4301 AND 4225 BUENA VISTA ROAD		TELEPHONE:	(661) 837-1337
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93311
CAPACITY:	164	CENSUS: 96	DATE:	01/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Administrator Pamela Bradley and Health Service Director Annette Eggleston		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 01/23/24, Licensing Program Analyst (LPA) M. Yang arrived at the facility unannounced to conduct the Required Annual Inspection. LPA were greeted by receptionist, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Health Service Director (HSD) Annette Eggleston. Administrator (A1) Pamela Bradley arrived shortly. LPA conducted tour of facility with A1. Residents were observed seating in dining room and in memory care gathering room. Facility consists of Assisted Living (AL) and Memory Care (MC) Unit. There are 57 residents on the Assisted Living side and 40 residents in Memory Care unit. LPA toured a sample of resident bedrooms in Assisted Living and Memory Care. Facility has sufficient furnishings inside and outside for resident use. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards. Facility is equipped with pull stations and fire sprinklers throughout facility. Fire extinguisher was observed throughout the facility with a service date of: 10/26/23. LPA observed pull cords in resident bedrooms. Hot water temperature measured at 112.2 degrees in room 112, 111.6 degrees in room 105, 110.7 degrees in room 209, 111.6 degrees in room 24, and 110.8 degrees in room 21. LPA observed securely fastened grab bars and non-skid surfaces/mat in shower. Bathroom was observed operational. Medications were stored in a locked medication room in a medication cart. MARs and medications were reviewed. LPA observed exits in Memory Care to have a 30-second delay egress. Kitchen was toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in walk-in freezer, walk-in refrigerator, and walk-in pantry. Walk-in refrigerator temperature was maintained at 38 degree F. and walk- in freezer was maintained at -12 degree F.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: IVY PARK AT SEVEN OAKS	FACILITY NUMBER: 157209257
	VISIT DATE: 01/23/2024

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

The outside was toured and observed to be free from debris with outdoor seating available for residents.
Exits tested in Memory Care and functioning properly and observed to have a 30-second delay egress. Facility resident and staff files reviewed during inspection and observed to have all the required documents.

A deficiency is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6.

An exit interview was conducted. The following documents are requested and submitted to Fresno CCL by: 01/29/24. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, current liability insurance, and Administrator certificate. A copy of this report and appeal rights was provided to Administrator.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 01/24/2024 08:54 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: IVY PARK AT SEVEN OAKS	FACILITY NUMBER: 157209257
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

Centrally stored medicines shall be kept in a safe and locked place... not accessible to persons other than employees... This requirement is 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 when LPA and A1 observed in room 112, medications on the kitchen counter, in bathroom, and in kitchen cabinet unlock. Medications were observed in room 105 in bathroom cabinet unlock. Medications were also observed unlock in kitchen cabinet in room 218. Medications were observed unlock and accessible to residents poses an immediate health, safety or personal rights risk to person in care.
	POC Due Date: 01/24/2024
	Plan of Correction
1 2 3 4	Licensee shall ensure that all medications shall be locked and inaccessible to residents in care. Proof of medications removed and locked, inaccessible to residents shall be submitted to the department by POC due date 1/24/24.

Type A

Section Cited

CCR

87309(a)

87309(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is 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 when LPA and A1 observed knives and cleaning chemicals unlock in resident room 105, 112, and 218 stored unlocked accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/24/2024
	Plan of Correction
1 2 3 4	Licensee shall ensure that all sharps and chemicals shall be locked at all times and inaccessible to residents in care. Proof of sharps and chemicals removed and locked, inaccessible to residents shall be submitted to the department by POC due date 1/24/24.

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) -65-7912
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3