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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157209257
Report Date: 03/06/2023
Date Signed: 03/07/2023 03:44:38 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/17/2023 and conducted by Evaluator Mai Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20230217121216
FACILITY NAME:IVY PARK AT SEVEN OAKSFACILITY NUMBER:
157209257
ADMINISTRATOR:BRADLEY, PAMELAFACILITY TYPE:
740
ADDRESS:4301 AND 4225 BUENA VISTA ROADTELEPHONE:
(661) 837-1337
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:164CENSUS: 68DATE:
03/06/2023
UNANNOUNCEDTIME BEGAN:
01:11 PM
MET WITH:Administrator/ Executive Director Pamela BradleyTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility did not follow resident's admission agreement.
INVESTIGATION FINDINGS:
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On 3/6/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to deliver complaint finding on the above allegation. LPA introduced self, stated the purpose of the visit, and met with Administrator/ Executive Director Pamela Bradley.

During the course of the investigation record were reviewed and interview were conducted. Admission agreement was not updated to reflect the hours of one-on-one that the resident needed. The total charges that the facility was providing the responsible party did not agree nor sign to the charges. In additional there is no updated physician report or assessment that the resident needed a 24 hour one-on-one care.

Based on record reviewed and interview conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Under California Code of Regulations, Title 22, are being cited on the attached LIC 9099D. Plan of correction was discussed. An exit interview was conducted, and a copy of this report and appeal rights was provided to via email to Administrator.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 24-AS-20230217121216
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2023
Section Cited
CCR
87507(g)(3)(B)(1)
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Admission agreements shall specify the following: (3) Payment provisions, including the following: (B) Rate for additional items and services, including: 1. A comprehensive description of and the corresponding fee schedule for…items and services not included in the fees for basic services shall be listed.

This requirement was not met by:
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Facility administrator agrees to resend an updated bill statement that excludes the one-on- one 24 hour champion care charges to resident and resident’s responsible party. Copy of the updated bill statement shall be submitted to CCL by 3/31/23.
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Based on interview and records reviewed, the one-on-one charges were not outlined and not agreed by responsible party or resident in the admission agreement. The resident was charged for one on one 24-hour champion care which possess a potential health and safety and personal rights risk to the resident in care.
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Any additional services included one-on-one care, admission agreement shall be updated with description and total of services fee that charged signed and approved by resident or responsible party.
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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: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023
LIC9099 (FAS) - (06/04)
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