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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209257
Report Date: 07/18/2023
Date Signed: 07/18/2023 10:52:43 AM


Document Has Been Signed on 07/18/2023 10:52 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 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: 84DATE:
07/18/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Administrator/ Executive Director Pamela BradleyTIME COMPLETED:
10:51 AM
NARRATIVE
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On 07/18/23, Licensing Program Analyst (LPA) M. Yang conducted case management deficiency
visit to the facility. LPA introduce self, stated the purpose of the visit and met with Administrator/ Executive Director Pamela Bradley

The purpose of the visit is to address incident that occurred where R1 went AWOL on 07/10/23.

Therefore, as mentioned, R1 went AWOL from facility. As a result, a deficiency is being cited, per California
Code of Regulations, Title 22, Division 6, see attached 809D.

A deficiency is being cited, per California Code of Regulations, Title 22, Division 6, see attached Lic 809D.

An exit interview was conducted. A copy of this report and appeal rights was provided to Administrator/Executive Director, whose signature confirms receipt of this report.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023
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 2


Document Has Been Signed on 07/18/2023 10:52 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: 07/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/19/2023
Section Cited
CCR
87413(a)(2)

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87413(a)(2) a) In each facility: (2) Care and supervision of residents shall be provided without physical or verbal abuse, exploitation or prejudice.

This requirement is not met as evidenced by:
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Licensee shall submit a plan detailing steps the facility will take to ensure the requirements are met by 07/19/23.

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Based on interview and record review, staff did not provide care and supervision when memory care R1 left the facility unsupervised on 07/10/23 at approximately 07:35PM. The facility was not aware R1 went AWOL until approximately at 07:47 PM when the facility was notified by the neighboring building that the resident was in their building lobby. This poses an immediate health and safety risks to persons in care.
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Licensee has agreed to submit AWOL in-service training and rooster of staff attendance to the Department by 08/01/23.

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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: 07/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023
LIC809 (FAS) - (06/04)
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