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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202497
Report Date: 08/29/2022
Date Signed: 08/29/2022 01:21:27 PM


Document Has Been Signed on 08/29/2022 01:21 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
CCLD Regional Office, 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: 84DATE:
08/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Administrator, Eduardo RangelTIME COMPLETED:
01:00 PM
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On 08/29/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a annual inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Eduardo Rangel.

LPA conducted a facility tour with Administrator. 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 non-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.

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.

LPA is requesting the following documents be submitted to the Fresno CCL office by 09/12/2022: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for(LIC9020A), Surety Bond

No deficiencies issued during today's inspection. Exit interview conducted. A copy of this report was discussed and provided to Administrator, Eduardo Rangel, whose signature on this form confirms receipt of the document.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2022
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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