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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157204131
Report Date: 01/14/2025
Date Signed: 01/14/2025 11:17:24 AM

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
09/11/2024 and conducted by Evaluator Mai Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240911151955
FACILITY NAME:PACIFICA SENIOR LIVING BAKERSFIELD MEMORY CAREFACILITY NUMBER:
157204131
ADMINISTRATOR:OHANIAN, ANGELAFACILITY TYPE:
740
ADDRESS:3115 BROOKSIDE DRTELEPHONE:
(661) 862-9777
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:40CENSUS: 23DATE:
01/14/2025
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Douglas Rice, Administrator TIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility did not seek medical attention for a resident in care
INVESTIGATION FINDINGS:
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On 01/14/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to delivered complaint findings on the above allegation. LPA introduced self, stated the purpose of the visit and met with Administrator Douglas Rice.

The department conducted investigation. Based on the records reviewed and interviews conducted, on 04/20/2024, at approximately 1140 hours, R1 sustained a fall and S1 found her on the floor next to her bed. Facility staff failed to abide by the discharge instructions. Staff also failed to contact emergency medical services until approximately 1956 hours, upon R1’s daughter’s request. Therefore, the preponderance of evidence standard has been met, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC 9099D. An exit interview was conducted. A copy of this report and appeal rights was provided to the Administrator, whose signature on this form confirms receipt of this report.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 24-AS-20240911151955
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: PACIFICA SENIOR LIVING BAKERSFIELD MEMORY CARE
FACILITY NUMBER: 157204131
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/15/2025
Section Cited
CCR
87411(d)(3)
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87411(d)(3) Personnel Requirements - General Skill and knowledge required to provide necessary resident care and supervision…

This requirement was not met as evidence by:
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Facility shall review regulations 87411 and submit a written statement on steps facility will take to ensure regulations is met. Written statement is to be submitted to Fresno CCL by POC due date 01/15/25.
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Based on records review and interviews conducted, R1 sustained a fall and S1 found R1 next the resident’s bed. Staff failed to abide by the discharge instructions. Staff failed to contact emergency medical services until R1’s daughter instructions which poses an immediate health and safety risks to persons in care.
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All staff in-service training on providing resident care and supervision. Staff attendance rooster and topics of training material shall be submitted to the department by 02/03/25.
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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.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
09/11/2024 and conducted by Evaluator Mai Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240911151955

FACILITY NAME:PACIFICA SENIOR LIVING BAKERSFIELD MEMORY CAREFACILITY NUMBER:
157204131
ADMINISTRATOR:OHANIAN, ANGELAFACILITY TYPE:
740
ADDRESS:3115 BROOKSIDE DRTELEPHONE:
(661) 862-9777
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:40CENSUS: 23DATE:
01/14/2025
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Douglas Rice, Administrator TIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
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5
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7
8
9
Staff did not prevent a resident from sustaining fractures while in care.
INVESTIGATION FINDINGS:
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On 01/14/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to delivered complaint findings on the above allegation. LPA introduced self, stated the purpose of the visit and met with Administrator Douglas Rice.

During the course of the investigation, records were received, and interviews were conducted. On 04/03/24, at approximately 0115 hours, R1 sustained a fall in the bathroom floor, was sent to the hospital where R1 was diagnosed with left femur fracture and discharged back to the facility. During routine check R1 was found kneeling next to the resident’s bed. R1 had a call button but failed to use it. R1 was sent to the hospital and diagnosed with right femur fracture. R1 do not require a one to one staff. Based on records reviewed, the preponderance of evidence standard has not been met, therefore, the above allegation is found to be UNSUBSTANTIATED. An exit interview was conducted. A copy of this report was provided to the Administrator, whose signature on this form confirms receipt of this report.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3