Inspection Reports for Hallmark Of Bakersfield
2001 Akers Rd, Bakersfield, CA 93309, CA, 93309
Back to Facility ProfileInspection Report Summary
Most inspections found deficiencies related primarily to medication management, resident care, and staff training, with several complaint investigations substantiating issues such as delayed or incorrect medication administration and inadequate supervision leading to a resident eloping and hospitalization. The facility also faced citations for staff speaking inappropriately to residents and incomplete care documentation. The most recent report from August 16, 2025, substantiated medication administration delays and resulted in a civil penalty for repeat violations. Earlier complaints about elevator maintenance and staff behavior were unsubstantiated, and some investigations found no violations. While deficiencies have persisted over time, the facility has addressed some concerns, but medication management remains a recurring issue.
Deficiencies per Year
8
6
4
2
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 60
Capacity: 99
Deficiencies: 1
Aug 16, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations received on 2025-06-06 regarding medication administration and elevator maintenance at the facility.
Findings
The investigation substantiated that staff did not administer resident medications in a timely manner and mismanaged medication orders, resulting in missed doses. The allegation regarding elevator maintenance was unsubstantiated as the facility took prompt corrective actions.
Complaint Details
The complaint investigation was substantiated for allegations that staff did not administer medications timely and mismanaged medication orders, specifically for resident R1. The elevator maintenance allegation was unsubstantiated. A civil penalty was issued for repeat medication violations.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to assist residents with self-administered medications in a timely manner, evidenced by delayed medication administration and missed doses for resident R1. | Type A |
Report Facts
Capacity: 99
Census: 60
Deficiency Type A: 1
Plan of Correction Due Date: Aug 18, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shawna Doucette | Licensing Program Analyst | Conducted the complaint investigation |
| Tiffany Luaces | Wellness Director | Facility representative who assisted with the investigation |
| Ashley L. Candelas | Administrator | Facility administrator involved in the investigation |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 99
Deficiencies: 1
Mar 27, 2025
Visit Reason
An unannounced complaint investigation was conducted based on complaints alleging that a resident eloped from the facility due to lack of care or supervision and that staff did not give resident medication as prescribed.
Findings
The investigation substantiated the allegation that the facility failed to provide adequate care and supervision, resulting in a resident eloping and being hospitalized. The medication administration complaint was found to be unfounded and dismissed.
Complaint Details
The complaint investigation was substantiated for the allegation that a resident eloped due to lack of care or supervision. The allegation that staff did not give resident medication as prescribed was found to be unfounded and dismissed.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not ensure care and supervision for resident R1 who eloped from the facility on 3/1/25, resulting in hospitalization and posing an immediate health and safety risk. | Type A |
Report Facts
Capacity: 99
Census: 62
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Candelas | Administrator | Named in care and supervision deficiency and involved in investigation |
| Shawna Doucette | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 99
Deficiencies: 1
Mar 19, 2025
Visit Reason
An unannounced complaint investigation was conducted due to allegations that staff spoke inappropriately to residents in care.
Findings
The investigation substantiated that staff spoke inappropriately to residents, with consistent statements from residents and evidence that staff responses to resident arguments were inappropriate.
Complaint Details
The complaint alleging inappropriate staff speech to residents was substantiated based on interviews and records review.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not ensure staff member S1 spoke appropriately to residents in care, violating personal rights and posing potential health and safety risks. | Type B |
Report Facts
Capacity: 99
Census: 62
Plan of Correction Due Date: Apr 8, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Candelas | Administrator | Met with Licensing Program Analyst during complaint investigation |
| Shawna Doucette | Licensing Program Analyst | Conducted the complaint investigation |
| Alexandria Walton | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Annual Inspection
Census: 60
Capacity: 99
Deficiencies: 5
Mar 5, 2025
Visit Reason
The inspection was an unannounced required annual inspection conducted by Licensing Program Analyst Shawna Doucette to evaluate compliance with licensing regulations at the facility.
Findings
The inspection found several deficiencies including lack of a labeled prescription for aspirin for resident R7, absence of centrally stored medication logs, incomplete hospice care plans, insufficient staff training hours, and inadequate food supply of nonperishable items. The facility also had some safety features in place such as fire alarms and extinguishers.
Severity Breakdown
Type A: 1
Type B: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Resident R7 did not start Vitamin D medication on the correct date, posing an immediate health, safety or personal rights risk. | Type A |
| Staff member S1 did not have the required 20 hours of training, including dementia care and hospice care training. | Type B |
| Facility did not maintain a seven day supply of nonperishable food for 60 residents. | Type B |
| Facility did not have centrally stored logs for medications for residents. | Type B |
| Facility did not have a completed hospice care plan for resident R1 listing facility staff responsibilities. | Type B |
Report Facts
Census: 60
Total Capacity: 99
Deficiencies cited: 5
POC Due Date: Mar 6, 2025
POC Due Date: Mar 7, 2025
POC Due Date: Mar 12, 2025
POC Due Date: Mar 21, 2025
POC Due Date: Mar 28, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley L. Candelas | Administrator | Met with Licensing Program Analyst during inspection and named in report |
| Shawna Doucette | Licensing Program Analyst | Conducted the inspection and authored the report |
| Alexandria Walton | Licensing Program Manager | Supervisor named in the report |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 99
Deficiencies: 1
Nov 7, 2024
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that staff mishandled residents' medications.
Findings
The investigation substantiated the allegation that a resident (R5) was administered medication more frequently than prescribed, violating medication administration orders. Another allegation regarding staff behavior posing a risk to residents was unsubstantiated due to lack of evidence.
Complaint Details
The complaint investigation was substantiated for medication mishandling based on records and interviews. The allegation that staff behavior posed a risk to residents was unsubstantiated due to insufficient evidence.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The licensee failed to assist residents with self-administered medications as needed, evidenced by R5 being administered Acetaminophen twice within less than 4 hours contrary to doctor's orders. | Type A |
Report Facts
Capacity: 99
Census: 64
Deficiency Type: 1
Plan of Correction Due Date: Nov 8, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Candelas | Administrator | Met with Licensing Program Analyst during investigation |
| Shawna Doucette | Licensing Program Analyst | Conducted the complaint investigation |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 99
Deficiencies: 0
Sep 4, 2024
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations including failure to prevent the spread of COVID, facility disrepair, unmet laundry needs, restricted restroom access, and inadequate nutrition.
Findings
The investigation found the facility was following COVID-19 protocols, had repaired the elevator, provided laundry services including use of a laundromat, allowed resident access to restrooms with a key system, and provided nutritious meals. There was insufficient evidence to substantiate the allegations, resulting in an unsubstantiated finding.
Complaint Details
The complaint investigation was unsubstantiated due to lack of preponderance of evidence to prove the alleged violations occurred.
Report Facts
Facility capacity: 99
Resident census: 58
Date complaint received: Aug 28, 2024
Elevator repair date: Aug 22, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shawna Doucette | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Ashley L. Candelas | Administrator | Facility administrator met during investigation |
Inspection Report
Annual Inspection
Census: 54
Capacity: 99
Deficiencies: 1
Mar 26, 2024
Visit Reason
The inspection was a continuation annual visit conducted to review facility files, including resident and employee records, and assess compliance with training requirements.
Findings
The inspection found that while general diabetes training was provided, the facility staff did not have specific training regarding the needs of Resident 3, resulting in a cited deficiency.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility staff did not have specific training regarding Resident 3 needs, posing a potential health, safety, or personal rights risk. | Type B |
Report Facts
Resident files reviewed: 5
Employee files reviewed: 5
Plan of Correction Due Date: Apr 5, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Candelas | Administrator | Met with Licensing Program Analyst during inspection |
| Darius Williams | Licensing Program Analyst | Conducted the inspection and cited deficiency |
| Serigy Pidgirny | Licensing Program Manager | Supervisor of Licensing Program Analyst |
Inspection Report
Annual Inspection
Census: 54
Capacity: 99
Deficiencies: 0
Mar 6, 2024
Visit Reason
An unannounced Annual inspection visit was conducted to evaluate the facility's compliance with licensing requirements.
Findings
The Licensing Program Analyst observed the facility to be generally clean and in good repair, with operational safety systems and required postings present. Due to insufficient time, the analyst was unable to review files and facility documents and will return to complete the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Candelas | Administrator | Met with Licensing Program Analyst during the inspection and discussed the purpose of the visit. |
| Darius Williams | Licensing Program Analyst | Conducted the unannounced Annual inspection visit. |
| Serigy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Census: 60
Capacity: 99
Deficiencies: 1
Jan 27, 2024
Visit Reason
An unannounced Case Management visit was conducted to review incidents involving aggressive behavior between residents and to assess compliance with Title 22 regulations.
Findings
The inspection found that Resident 1 violated the personal rights of Resident 2 on multiple occasions, posing potential health, safety, and personal rights risks. The facility was unable to provide an itemized list of Resident 1's personal belongings.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Resident 1 has violated the personal rights on Resident 2 on several occasions during documented incidents, posing a potential health, safety, or personal rights risk to residents in care. | Type B |
Report Facts
Deficiency Plan of Correction Due Date: Feb 10, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Alfano | Facility Medication Technician | Met during visit and involved in exit interview |
| Sarah Hurt | Licensing Program Analyst | Conducted the inspection and authored the report |
| Brenda Chan | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 99
Deficiencies: 0
Jan 27, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 01/25/2024 regarding staff preventing residents from having visits and not safeguarding residents' personal items.
Findings
The complaint that staff were preventing residents from having visits was found to be unfounded with no basis. The allegation that staff did not safeguard residents' personal items was unsubstantiated due to lack of preponderance of evidence, with some confusion over clothing items corrected by staff. No deficiencies were cited.
Complaint Details
The complaint investigation involved two allegations: 1) Staff preventing resident visits, which was found to be unfounded, and 2) Staff not safeguarding resident's personal items, which was unsubstantiated. The investigation included interviews with facility staff and review of evidence. No violations were confirmed.
Report Facts
Capacity: 99
Census: 51
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Alfaro | Facility Medication Technician | Interviewed during complaint investigation and named in findings |
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation visit |
| Ashley L. Candelas | Administrator | Facility administrator named in report header |
Inspection Report
Original Licensing
Census: 45
Capacity: 99
Deficiencies: 0
Feb 23, 2023
Visit Reason
The inspection was a pre-licensing visit conducted to evaluate the facility prior to issuing a license.
Findings
The facility was toured and observed to have appropriate safety measures, sanitary kitchen conditions, locked storage for medications and chemicals, and adequate resident accommodations. Seven staff files were reviewed and confirmed for criminal record clearances. No license was issued at the time, and the report will be forwarded for further review.
Report Facts
Staff files reviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the pre-licensing inspection and exit interview |
| Ashley Candelas | Administrator | Facility administrator met with Licensing Program Analyst during inspection |
Inspection Report
Original Licensing
Census: 47
Capacity: 99
Deficiencies: 0
Feb 9, 2023
Visit Reason
The visit was conducted as part of the Component II completion for a Change in Ownership (CHOW) application for the Residential Care Facility for Elderly (RCFE).
Findings
The applicant successfully completed Component II, demonstrating understanding of community care facility licensing laws and regulations. The evaluation confirmed the applicant's knowledge in areas including facility operation, admission policies, staffing, emergency preparedness, and complaints reporting.
Report Facts
Capacity: 99
Census: 47
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley L. Candelas | Administrator | Named as facility administrator |
| Shlomo Aron | Applicant | Participated in Component II interview |
| Darla Neeley | Licensing Program Manager | Named in report signature section |
| Celia Phomphachanh | Licensing Program Analyst | Named in report signature section |
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