107202497-6-1-2023-24-AS-BCHN-CSDSK8-20230601135618

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107202497
Report Date: 05/19/2023
Date Signed: 06/01/2023 01:22:48 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
02/27/2023 and conducted by Evaluator Vadim Gorban

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20230227143655

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: 79	DATE:	05/19/2023
		UNANNOUNCED	TIME BEGAN:	08:38 AM
MET WITH:	Administrator, Eddie Rangel		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff did not follow resident care plan resulting in hospitalization
Administrator not responding to resident's representative

INVESTIGATION FINDINGS:

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On 5/19/23 Licensing Program Analyst (LPA) V Gorban visited facility stated above to deliver findings. LPA met with Administrator Eddie Rangel, explained the purpose of the visit. LPA toured facility inside and out, observed residents in care and discussed findings to allegations.

Allegation: Staff did not follow resident care plan resulting in hospitalization

Department investigated complaint. LPA reviewed facility records. Facility utilizing Needs and services plan to provide care for residents. Needs and services pan was provided to department. Based on records review and interviews facility followed residents care plan. 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.

...Continuation on a next page LIC9099-C

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: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

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-20230227143655

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: 05/19/2023

NARRATIVE

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Allegation: Administrator not responding to resident's representative

Department investigated complaint, reviewed files, and interviewed administrator and staff. Based on interview administrator confirmed responding to resident’s representative. Facility representatives stated that RP was requesting information regarding R1 even though RP was not on emergency contact information responsible party. 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.

Exit interview conducted, report signed, printed, and 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: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

LIC9099 (FAS) - (06/04)

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