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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107202497
Report Date: 07/12/2021
Date Signed: 07/12/2021 04:42:15 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/29/2021 and conducted by Evaluator Alexandria Walton
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20210129145303
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: 83DATE:
07/12/2021
UNANNOUNCEDTIME BEGAN:
12:38 PM
MET WITH:Administrator, Eddie RangelTIME COMPLETED:
12:50 PM
ALLEGATION(S):
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Resident's responsible party not provided with a new admission agreements
INVESTIGATION FINDINGS:
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On 07/12/2021, Licensing Program Analyst (LPA) arrived unannounced at the above facility. LPA entered the facility, introduced self, and requested to meet with Administrator. LPA met with Administrator, Eddie Rangel. The purpose of today's visit is to deliver findings on the above allegation.

On 06/24/2021, LPA conducted an Annual Inspection. During the inspection, LPA reviewed records and observed that residents R1 and R2 did not have current Admission Agreements with the above facility. LPA confirmed with Administrator that all residents residing at the facility, during the change of ownership, did not receive updated Admission Agreements from the above faciltiy. New residents, that were admitted after the change of ownership, received Admission Agreements from the above facility.

CONTINUED TO 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/29/2021 and conducted by Evaluator Alexandria Walton
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20210129145303

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: 83DATE:
07/12/2021
UNANNOUNCEDTIME BEGAN:
12:38 PM
MET WITH:Administrator, Eddie RangelTIME COMPLETED:
12:50 PM
ALLEGATION(S):
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8
9
Residents are not being assisted with medication in a timely manner
Staff not attending to resident's call light
INVESTIGATION FINDINGS:
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13
On 07/12/2021, Licensing Program Analyst (LPA) arrived unannounced at the above facility. LPA entered the facility, introduced self, and requested to meet with Administrator. LPA met with Administrator, Eddie Rangel. The purpose of today's visit is to deliver findings on the above allegations.

During the course of the investigation, LPA reviewed records and interviewed residents and staff.

Based on interviews and record reviews the above allegations are found to be UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No deficiencies issued. An exit interview was conducted with Administrator. A copy of this report was discussed and provided to Administrator via email and an electronic read receipt confirms receiving this document. Facility Representative signature on file.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 24-AS-20210129145303
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: PACIFICA SENIOR LIVING FRESNO
FACILITY NUMBER: 107202497
VISIT DATE: 07/12/2021
NARRATIVE
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Based on observation and interviews, the preponderance of evidence standard has been met, therefore the allegation: Resident's responsible party not provided with a new admission agreements is found to be SUBSTANTIATED.

A deficiency is being cited in accordance to California Code of Regulations, Title 22, Division 6, see attached 9099D.

An exit interview was conducted. A Plan of Correction was reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and provided to Administrator via email and an electronic read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 24-AS-20210129145303
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PACIFICA SENIOR LIVING FRESNO
FACILITY NUMBER: 107202497
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2021
Section Cited
CCR
87507(a)
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87507 Admission Agreements: (a) The licensee shall complete an individual written admission agreement...with each resident or the resident's representative... This requirement was not met as evidenced by:
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Licensee agreed to submit a plan detailing steps the facility will take to ensure the requirements of Admission Agreements are being met, to the Fresno CCL office by 08/12/2021.
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Based on observation and interviews, resident's and/or the residents representative were not provided updated Admission Agreement after the change of ownership. This poses a potential health and safety risk to residents in care.
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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: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6