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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202497
Report Date: 07/20/2023
Date Signed: 07/21/2023 03:11:24 PM


Document Has Been Signed on 07/21/2023 03:11 PM - 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: 77DATE:
07/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator Eddie RangelTIME COMPLETED:
10:00 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 7/20/23, Licensing Program Analyst (LPA) V Gorban conducted an unannounced case management at 830 hours. LPA met with Administrator Eddie Rangel. The purpose of this visit is to deliver the finding of review completed by the Department.

LPA conducted a tour of the facility, interior and exterior to ensure there are no potential or immediate health and safety risk at the facility.

On 11/22/2022, the Department received a complaint and conducted the investigation. During the course of investigation, it was discovered that the facility failure to sufficiently monitor, or document monitoring of resident (R1) during COVID recovery and adherence to medical advice.
Based on the review conducted by the Department and information gathered, the following deficiency was cited on LIC 809-D per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8. An immediate civil penalty of $500.00 was issued at this time and a copy of the LIC 421IM was given to Administrator.

An exit interview was conducted, and a copy of this report dated and signed along with Administrator. Appeal Rights (LIC 9058) was provided to Administrator whose signature below confirms receipt of these rights.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023
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 07/21/2023 03:11 PM - 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: PACIFICA SENIOR LIVING FRESNO
FACILITY NUMBER: 107202497

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/20/2023
Section Cited
CCR
87465(a)(1)

1
2
3
4
5
6
7
87465 INCIDENTAL MEDICAL AND DENTAL CARE SERVICES 87465 (a)
) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
1
2
3
4
5
6
7
Licensee stated that staff training on meeting each resident’s medical needs will be conducted on monthly bases. Licensee agrees to develop a written plan of correction (POC) describing in writing how facility shall ensure compliance with CCR 87465 and how similar incident related to violation will be prevented in the future for health and safety of residents. POC shall be received in licensing office by fax and/or mail by due date 7/21/23.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Based on the Department’s review, licensee failed to ensure that such arrangement for medical care appropriate to the condition and need of resident. R1 did not receive proper care during COVID recovery resulting in engaging in activities outside R1’s room which poses an immediate health; safety or personal rights risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

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: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2