<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202497
Report Date: 11/01/2022
Date Signed: 11/01/2022 10:38:17 AM


Document Has Been Signed on 11/01/2022 10:38 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:PACIFICA SENIOR LIVING FRESNOFACILITY NUMBER:
107202497
ADMINISTRATOR:RANGEL, EDUARDOFACILITY TYPE:
740
ADDRESS:1715 E ALLUVIAL AVETELEPHONE:
(559) 298-4900
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:100CENSUS: 78DATE:
11/01/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH:Administrator, Eddie RangelTIME COMPLETED:
10:51 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/01/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a case management visit. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Eddie Rangel (AD).

The purpose of today's visit is to follow up on documentation submitted to the Fresno CCL Office. It was reported that an inspection was conducted by the Fire Department (FD) on 09/01/2022. During the inspection conducted by FD, the following was observed: Fire door smoke gaskets were observed partially missing or completely missing, the fire door in the laundry room is damaged, fire rated doors did not latch completely when shut, a fire alarm notification device was not observed in the assisted living dining room, documentation that the fire sprinkler system has been tested annually not provided, a fire sprinkler cover plate was missing, caps to the commercial automatic fire-extinguishing system are in place, the automatic fire-extinguishing system for the commercial cooking hoods last serviced 02/2022 and is past due, documentation that the fire sprinkler system has been tested annually not provided, documentation showing the last inspection for fire pumps and weekly diesel fire pump runs not provided, documentation of the carbon monoxide device testing not provided, the recreation room was observed with thumb latch locks and should be removed, several exit access pathways were partially obstructed by scooters, emergency lights throughout the facility could not be tested during the inspection, doors on a cabinet containing flammable liquids did not self close and latch.

Based on record review a deficiency is being issued in accordance to California Code of Regulations, Title 22 on the attached 809 D. An immediate civil penalty in the amount of $500 is being assessed.

Exit interview conducted and a plan of correction was reviewed and developed. A copy of this report and appeal rights were discussed and provided to AD, whose signature on this form confirms receipt of this document.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2022
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 11/01/2022 10:38 AM - 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: PACIFICA SENIOR LIVING FRESNO
FACILITY NUMBER: 107202497

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/02/2022
Section Cited

1
2
3
4
5
6
7
87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement was not met as evidenced by:
8
9
10
11
12
13
14
Based on recored review the facility did not ensure the requirements for the above section were met when Fire door smoke gaskets were observed partially missing or completely missing, the fire door in the laundry room is damaged, fire rated doors did not latch completely when shut, a fire alarm notification device was not observed in the assisted living dining room, documentation that the fire sprinkler system has been tested annually not provided, a fire sprinkler cover plate was missing, caps to the commercial automatic fire-extinguishing system are in place, the automatic fire-extinguishing system for the commercial cooking hoods last serviced 02/2022 and is past due, documentation that the fire sprinkler system has been tested annually not provided, documentation showing the last inspection for fire pumps and weekly diesel fire pump runs not provided, documentation of the carbon monoxide device testing not provided, the recreation room was observed with thumb latch locks and should be removed, several exit access pathways were partially obstructed by scooters, emergency lights throughout the facility could not be tested during the inspection, doors on a cabinet containing flammable liquids did not self close and latch; this requirement was not met as evidenced.
8
9
10
11
12
13
14
Licensee also agreed to correct all violations and submit all documentation to the Fresno CCL office by 11/30/2022.

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2