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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107202497
Report Date: 11/03/2021
Date Signed: 11/03/2021 01:58:44 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
07/09/2021 and conducted by Evaluator Alexandria Walton
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20210709101540
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: 77DATE:
11/03/2021
UNANNOUNCEDTIME BEGAN:
11:09 AM
MET WITH:Executive Director, Eddie RangelTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not issue a refund in a timely manner
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/03/2021, Licensing Program Analyst (LPA) A. Walton arrived unannounced to deliver findings on the above allegations. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Executive Director, Eddie Rangel.

During the course of this investigation, LPA reviewed records and conducted staff interviews.

Interviews with staff revealed, that during an absence, Residents at the above facility are charged for the full monthly rate which does not include the Medication Program Fee and the Level of Care charge fee. Facility records revealed that R1 was not in the facility from 03/19/2021-04/26/2021 and again from 05/16/2021-06/15/2021.

Continued to LIC9099C
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: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
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 5
Control Number 24-AS-20210709101540
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: 11/03/2021
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
26
27
28
29
30
31
32
During R1’s absence, it was confirmed with staff that R1 was charged for the Medication Program Fee and Level of care charge. LPA confirmed with facility staff that a refund was not provided for the Medication Program Fee and Care charge upon R1’s departure from the facility.

Based on review of records, it appears that R1 is owed an additional $2,747.97. The facility was unable to provide a detailed statement explaining the charges and credits on the billing statement and was unable to provide proof that the correct refund amount was provided to R1. Facility was also unable to provide documentation of when R1’s personal belongings were removed from the facility.

Based on records review and interviews conducted, the preponderance of evidence standard has been met, therefore the allegation: Facility did not issue a refund in a timely manner is found to be SUBSTANTIATED.

A deficiency is being cited in accordance to California Code of Regulations, Title 22, Division 6, see LIC9099D.

An exit interview was conducted, and a Plan of Correction was reviewed and developed with the Administrator. Due to COVID-19 precautionary measures, a copy of this report and Appeal Rights will be provided via email to the Executive Director and an electronic read receipt confirms receiving this document. Report signed on-site by Facility Representative.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 24-AS-20210709101540
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: 11/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/03/2021
Section Cited
HSC
1569.652(c)
1
2
3
4
5
6
7
§1569.652(c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual,... or entity contractually responsible for the fees... within 15 days after the personal property is removed. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee agrees to provide proof of a refund for the Medication Program Fees and Care Charges accrued during R1's absence and provide a detailed billing statement that includes details of charges and credits for R1 to the Fresno CCL office by 12/03/2021.
8
9
10
11
12
13
14
Based on interviews and records review: The facility did not provide a refund for the charges that accrued for the Medication Program fees and Level of Care charge fees during R1’s absence from the facility. Records indicate that R1 was absent from the facility from 03/19/2021-04/26/2021 and 05/16/2021-06/15/2021.
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: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
07/09/2021 and conducted by Evaluator Alexandria Walton
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20210709101540

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: 77DATE:
11/03/2021
UNANNOUNCEDTIME BEGAN:
11:09 AM
MET WITH:Executive Director, Eddie RangelTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff mismanaged residents funds
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/03/2021, Licensing Program Analyst (LPA) A. Walton arrived unannounced to deliver findings on the above allegations. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Executive Director, Eddie Rangel.

During the course of this investigation, LPA reviewed records and conducted staff interviews.

Interviews with staff revealed that an error had occurred on R1’s billing statement regarding a payment that was not received. R1 provided proof that the payment had cleared from R1’s account. The facility returned the funds to R1.

Continued to LIC9099C
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: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 24-AS-20210709101540
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: 11/03/2021
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
26
27
28
29
30
31
32
Based on interview conducted with staff and review of records, the allegation: Facility staff mismanaged residents funds, is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

No deficiencies issued.

An exit interview was conducted with Executive Director. As a COVID-19 precautionary measure, a copy of this report will be provided to the Executive Director via email and an electronic read receipt confirms receiving this document.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5