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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202497
Report Date: 06/24/2021
Date Signed: 06/24/2021 12:01:17 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:PACIFICA SENIOR LIVING FRESNOFACILITY NUMBER:
107202497
ADMINISTRATOR:NATASHA HAGOPIANFACILITY TYPE:
740
ADDRESS:1715 E ALLUVIAL AVETELEPHONE:
(559) 298-4900
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:100CENSUS: DATE:
06/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:37 AM
MET WITH:Administrator, Eduardo RangelTIME COMPLETED:
12:00 PM
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On 06/24/2021, Licensing Program Analyst (LPA) Walton arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit and requested to speak with the Administrator. LPA met with Administrator (ADM), Eduardo Rangel. Facility has one central entry and exit point. Upon entry, LPA observed visitor log-in/temperature check.

LPA conducted a facility tour with ADM. All pathways, entrances and exits were clear from obstructions. No fire clearance issues. LPA observed signs promoting hand-washing, social distancing, and cough/sneeze etiquette. Facility staff observed to be wearing facial coverings. LPA toured the facility kitchen. LPA observed a 7-day supply of perishable foods and a 2-day supply of perishable foods. LPA observed a 30 day supply of PPE and cleaning supplies. LPA checked residents' medications and observed a 30 day supply. Facility orders medication refills 7-10 day in advance. Residents temperature checks are documented daily.

Residents at the above facility have private apartments. LPA observed hand sanitizer dispensers in the facility hallways. Facility bathrooms were stocked with paper towels and liquid soap. Hand-washing signs observed in bathrooms. Resident records have updated emergency contact information. Facility staff records reviewed for good health and infection control training. Administrator certificate is current.

No deficiencies issued during this inspection.

Exit interview conducted. As a COVID-19 precautionary measure, a copy of this report will be provided to ADM via email and an electronic read receipt confirms receiving this document. ADM was informed to select yes when prompted to send a read receipt. Facility Representative signature on file.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021
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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