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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157204131
Report Date: 01/14/2025
Date Signed: 01/14/2025 11:21:03 AM

Document Has Been Signed on 01/14/2025 11:21 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:RIVERSTONE TERRACE SENIOR LIVING MEMORY CAREFACILITY NUMBER:
157204131
ADMINISTRATOR/
DIRECTOR:		RICE, DOUGLAS G.FACILITY TYPE:
740
ADDRESS:3115 BROOKSIDE DRTELEPHONE:
(661) 862-9777
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 40CENSUS: 23DATE:
01/14/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:40 AM
MET WITH:Douglas Rice, Administrator TIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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On 01/14/25, Licensing Program Analyst (LPA) M. Yang arrived to unannounced to conduct case management deficiency visit and met with Administrator Douglas Rice.

During the course of the investigation for complaint 24-AS-20240911151955, staffs were interviewed during the complaint investigation. Five staff that were interviewed were found not to be associated with the facility during the time of the complaint investigation.

A deficiency is being cited and an immediate Civil Penalty were assessed. See Lic 421BG is being cited on
the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6.
Exit interview conducted. A copy of this report and appeal rights was provided to Administrator, whose
signature confirms receipt of this report.
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/14/2025 11:21 AM - It Cannot Be Edited


Created By: Mai Yang On 01/14/2025 at 10:41 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: RIVERSTONE TERRACE SENIOR LIVING 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
87355(e)(2)

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87355(e)(2) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)

This requirement is not met as evidenced by:
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S1 is no longer employed with the facility effective 11/01/24. S3 is immediately removed from the premise. S1, S2, S3, S4, and S5 is not permitted on the premise until associated.
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During course of a complaint investigation for complaint 24-AS-20240911151955, it was found that S1, S2, S3, S4, and S5 were not associated to the facility which poses an immediate risk to the health and safety of the residents.
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Proof of S2, S3, S4, and S5 associated to the facility shall be submitted to the department by 1/15/25.

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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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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