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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209257
Report Date: 01/15/2025
Date Signed: 01/15/2025 03:50:21 PM

Document Has Been Signed on 01/15/2025 03:50 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/
DIRECTOR:		BRADLEY, PAMELAFACILITY TYPE:
740
ADDRESS:4301 AND 4225 BUENA VISTA ROADTELEPHONE:
(661) 837-1337
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 164CENSUS: 100DATE:
01/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Administrator Pamela Bradley and Memory Care Director Mikayla Goulart TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 01/15/25, Licensing Program Analyst (LPA) M. Yang arrived at the facility unannounced to conduct the
Required Annual Inspection. LPA were greeted by receptionist, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator (A1) Pamela Bradley and Memory Care Director Mikayla Goulart. LPA conducted tour of facility with A1. Residents were observed seating in dining room and in memory care dining room.

Facility consists of Assisted Living (AL) and Memory Care (MC) Unit. There are 62 residents on the Assisted Living side and 38 residents in Memory Care unit.

The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards. Facility is equipped with pull stations and fire sprinklers throughout facility. Fire extinguisher was observed throughout the facility with a service date of: 10/25/24 LPA observed pull cords in resident bedrooms.

Kitchen was toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in walk-in freezer, walk-in refrigerator, and walk-in pantry. Walk-in refrigerator temperature was maintained at 38 degree F. and walk- in freezer was observed at 38 degree F.

LPA toured a sample of resident bedrooms in Assisted Living and Memory Care. Facility has sufficient furnishings inside and outside for resident use.

Hot water temperature measured at 114.2 degrees F in room 112, 113.8 degrees F in room 107, 113.1 degrees F in room 213, 130.3 degrees F in room 27, 125.3 degrees F in room 46, and 122.5 degrees F in room 12.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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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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
VISIT DATE: 01/15/2025
NARRATIVE
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LPA observed securely fastened grab bars and non-skid mat in shower. Bathroom was observed operational. Medications were stored in a locked medication room in a medication cart. MARs and medications were reviewed.

The outside was toured and observed to be free from debris with outdoor seating available for residents. LPA observed exits in Memory Care to have a 30-second delay egress.

Facility resident and staff files reviewed during inspection and observed to have all the required documents.

A deficiency is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6.

An exit interview was conducted. The following documents are requested and submitted to Fresno CCL by: 01/21/25. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, current liability insurance, and Administrator certificate. A copy of this report and appeal rights was provided to Administrator.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/15/2025 03:50 PM - It Cannot Be Edited


Created By: Mai Yang On 01/15/2025 at 02:25 PM
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: IVY PARK AT SEVEN OAKS
FACILITY NUMBER: 157209257

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
87309(a)
87309(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when LPA observed tools and box cutters in room 112, a cleaning bottle in room 107 bathroom cabinet, and small knives stored in room 213 kitchen drawers, unlock accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/16/2025
Plan of Correction
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Knives were immediately locked in room 213 cabinet. Staff removed tools from room 112, cleaning bottle from room 107. POC cleared during visit.
Deficiency Dismissed
Type A
Section Cited
CCR
87465(c)(2)
87465 (c)(2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on records review and observation, R1’s medication Gabapentin 300 mg, R2’s medication Levothyroxine 100mcg, R2 medication Meloxicam 7.5 mg, R3 medication Divalproex 500 mg, and R3’s medication Vitamin D-3 2,000U were not administered as instructed by physician, which poses an immediate health and safety risk for the person in care.
POC Due Date: 01/16/2025
Plan of Correction
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Administrator agree to write statement of steps facility will take to ensure regulations is met. Statement will be submitted to Fresno CCL by POC due date 01/16/25.

All assisted living medication techicians shall be retrained on medication training which will also include administering medications and review medications. Documentation of training topics with staff attendance rooster shall be submitted to the Fresno CCL office by 02/04/25.
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: 01/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 01/15/2025 03:50 PM - It Cannot Be Edited


Created By: Mai Yang On 01/15/2025 at 02:27 PM
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: IVY PARK AT SEVEN OAKS
FACILITY NUMBER: 157209257

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
87303 (e)(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on observation, hot water temperature in memory care unit measured at 130.3 degrees F in room 27, 125.3 degrees F in room 46, and 122.5 degrees F in room 12, which poses/ posed a potential health and safety risk for the person in care.
POC Due Date: 01/21/2025
Plan of Correction
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The facility shall maintain hot water temperature between 105 degree F and 120 degree F. The facility shall have a daily temperature log to ensure water temperature meets the regulation requirements. Daily temperature log with proof of hot water temperature is tested and maintained between 105 degree and 120 degree F shall be submitted to the Fresno CCL office by 01/21/25.
Type B
Section Cited
CCR
87555(b)(21)
87555 (b)(21) Freezers of adequate size shall be maintained at a temperature of 0 degrees F (-17.7 degrees C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degrees F (4 degrees C). They shall be kept clean and food stored to enable adequate air circulation to maintain the above temperatures.

This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on interviews conducted, observation, and records reviewed, the facility walk in freezer was observed at 38 degrees F. Facility record show walk-in freezer temperature maintained between 2.4 and 34.9 degrees F, which posed/ poses a potential health and safety risk for the person in care.
POC Due Date: 01/21/2025
Plan of Correction
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Documentation the facility walk-in freezer temperature is maintained at 0 degrees or below shall be submitted to Fresno CCL office by POC due date 01/21/25.
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: 01/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2025


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