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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202497
Report Date: 06/02/2023
Date Signed: 06/06/2023 08:57:53 AM


Document Has Been Signed on 06/06/2023 08:57 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
SIERRA CASCADE AC/SC, 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: 79DATE:
06/02/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator, Eddie RangelTIME COMPLETED:
10:15 AM
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On 6/02/2023, Licensing Program Analyst (LPA) V Gorban conducted an unannounced Case Management visit.
LPA introduced self and was allowed entrance by staff. LPA Gorban met with Administrator Eddie Rangel.

LPA toured facility inside and out, observed residents in dining room during breakfast. LPA Gorban reviewed facility residents’ files. LPA Gorban reviewed independent and assisted living residents files. Facility maintained up to date residents files following Title 22 for both sections of facility.

No deficiencies cited during this Case Management visit.

An exit interview was conducted with Administrator Eddie Rangel. Report signed on-site and a copy of this report was provided for facility records.

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
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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