107202497-9-1-2023-24-AS-VGON-CV9U4W-20230901151546

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107202497
Report Date: 09/01/2023
Date Signed: 09/01/2023 03:16:46 PM

Document Has Been Signed on 09/01/2023 03:16 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 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: 84	DATE:	09/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:53 AM
MET WITH:	Executive Director, Eduardo Rangel		TIME COMPLETED:	01:00 PM

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 09/01/23, Licensing Program Analyst (LPA) V Gorban arrived at the facility unannounced to conduct Required Annual Inspection. LPA was greeted by receptionist and stated the purpose of the visit. LPA met with Executive Director (ED) Eduardo Rangel, certification number 6020138740 and expiration date 09/23/2024. LPA conducted tour of facility with ED. Residents were observed enjoying nice morning weather walking outside around the facility and others in common areas. The facility was observed to be at a comfortable temperature of 74 degree Fahrenheit, clean, in good repair, and no passageway obstructions or fire hazards observed. Fire extinguisher was observed with a service date of 03/24/23. Dining area and Kitchen were toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in walk-in freezer, walk-in refrigerator, and pantry. Food is delivered twice a week. Refrigerator temperature was maintained at 33.5 degree Fahrenheit and freezer was maintained at -5 degree Fahrenheit. LPA interviewed some of the residents. Residents' rooms were toured and observed with adequately furnished with bed, dresser, and adequate lighting. Hot water temperature tested at 106 degrees F. LPA observed securely fastened grab bars and non-skid mat in all shower areas. Medications were stored in a locked medication room in a medication cart. Medications records were reviewed. First Aid Kit was stored in medication room and observed with all required items. Adequate PPE supplies was observed. LPA toured laundry room and observed chemicals were stored and locked. Report continues on LIC809-C

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim Gorban	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

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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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
	VISIT DATE: 09/01/2023

NARRATIVE

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Facility courtyard was toured and observed to be free from debris. The outdoor seating furniture appeared to be functional and available for the residents.

A sample of residents’ file was reviewed to have updated emergency contact, Admission agreement, Needs and Services Plan and Pre-Appraisal Plan.

A sample of staff files were reviewed. Staff files were observed to have current First Aid/CPR, Health screening, and Personnel record. Staff are fingerprinted clear and associated to the facility.

An exit interview was conducted with ED. The following documents are requested to be submitted to Fresno CCL by: 09/05/23 : Lic 400, Lic 610E, Lic 9282, current Administrator certificate, updated facility sketch, and current liability insurance.

No deficiencies issued during this inspection.
A copy of this report was given to the ED, whose signature on this form confirm receipt of these reports.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim Gorban	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

LIC809 (FAS) - (06/04)

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