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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209257
Report Date: 07/24/2023
Date Signed: 07/24/2023 12:40:22 PM


Document Has Been Signed on 07/24/2023 12:40 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
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: 83DATE:
07/24/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Administrator/ Executive Director Pamela BradleyTIME COMPLETED:
12:40 PM
NARRATIVE
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On 07/24/23, Licensing Program Analyst (LPA) M. Yang conducted an unannounced case management- deficiency inspection regarding written incident report received from facility on 07/21/23. LPA met Administrator/ Executive Director Pamela Bradley.

The purpose of the today's visit is to follow up on the incident that occurred on 07/20/23. At 08:20 AM on 07/20/23, staff administered R1 the wrong medication. Staff immediately notified Memory Care Director.

A deficiency is being cited, per California Code of Regulations, Title 22, Division 6, see attached Lic 809D.
Exit Interview conducted. A copy of this report and appeal rights was provided to the Administrator.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2023
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 07/24/2023 12:40 PM - 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: 07/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/25/2023
Section Cited
CCR
87465(a)(5)

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87465(a)(5) The licensee shall assist residents with self-administered medications as needed.

This requirement was not met as evidenced by:
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S1 was retrained on administering medication on 07/20/23. LPA received copies of S1 in-service training and documentation. POC cleared during visit.
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Based on interview, R1 was administered R2’s medication by S1 which poses an immediate 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: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2023
LIC809 (FAS) - (06/04)
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