107202497-3-6-2023-24-AS-BCHN-CPQPG6-20230308101749

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107202497
Report Date: 03/03/2023
Date Signed: 03/06/2023 02:10:09 PM

Unsubstantiated

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
11/22/2022 and conducted by Evaluator Vadim Gorban

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20221122075852

FACILITY NAME:	PACIFICA SENIOR LIVING FRESNO		FACILITY NUMBER:	107202497
ADMINISTRATOR:	RANGEL, EDUARDO		FACILITY TYPE:	740
ADDRESS:	1715 E ALLUVIAL AVE		TELEPHONE:	(559) 298-4900
CITY:	FRESNO	STATE: CA	ZIP CODE:	93720
CAPACITY:	100	CENSUS: 78	DATE:	03/03/2023
		UNANNOUNCED	TIME BEGAN:	10:08 AM
MET WITH:	Administrator, Eddie Rangel		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff did not observe changes in resident’s health resulting in severe dehydration and hospitalization
Staff did not seek timely medical attention for resident
Staff left resident in feces
Staff did not ensure resident’s medication was administered
Staff did not ensure resident received meals/fluids
Staff are not wearing masks

INVESTIGATION FINDINGS:

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On 03/03/23, Licensing Program Analyst (LPA) V Gorban arrived to the facility unannounced to deliver findings on the above allegations. LPA stated the purpose of the visit and was allowed entry. LPA met with Administrator Eddie Rangel to discuss findings.

During the course of the investigation, LPA conducted interviews, record review of medical and facility files of Resident (R1's).

Allegation: Staff did not observe changes in resident’s health resulting in severe dehydration and hospitalization. Based on staff interviews and medical records review this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim Gorban	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 24-AS-20221122075852

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 FRESNO	FACILITY NUMBER: 107202497
	VISIT DATE: 03/03/2023

NARRATIVE

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Allegation: Staff did not seek timely medical attention for resident. Based on staff and residents interviews and files reviews this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Staff left resident in feces. Based on staff interviews and files reviews this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Staff did not ensure resident’s medication was administered. Based on staff, administrator and residents’ interviews and files reviews this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Staff did not ensure resident received meals/fluids. Based on staff, administrator and residents’ interviews and files review this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Staff are not wearing masks. Based on staff and residents interviews and history files review of similar allegations, this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies cited during this complaint visit. An exit interview was conducted. A copy of this report was provided to administrator for facility records.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim Gorban	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023

LIC9099 (FAS) - (06/04)

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