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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209116
Report Date: 02/02/2023
Date Signed: 02/02/2023 04:10:23 PM


Document Has Been Signed on 02/02/2023 04:10 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 FRESNOFACILITY NUMBER:
107209116
ADMINISTRATOR:RANGEL, EDDIEFACILITY TYPE:
740
ADDRESS:1715 E. ALLUVIAL AVENUETELEPHONE:
(619) 296-9000
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:100CENSUS: 78DATE:
02/02/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Admininstrator, Eddie RangelTIME COMPLETED:
11:32 AM
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Licensing Program Analysts (LPAs) V Gorban and B Miranda conducted an unannounced Pre-licensing visit for Change of ownership . LPA met with Administrator Eddie Rangel and discussed the purpose of the visit.
Facility, assisted living section, was observed at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. Common areas furnished and well-lit throughout. Social distancing is maintained. LPA observed the kitchen to be absent of any trash or debris. A two-day supply of perishable and seven-day supply of non-perishable food were observed.

Medications and chemicals were kept locked in separate cabinets. Resident’s bedroom and furniture supplied and provided by resident and once resident leaves the facility, they take their furniture with accessories they initially brought in with them.
Bathrooms and showers were equipped with non-skid mats and securely fastened grab bars. Towels, linens, and personal hygiene supplies were observed in storage.

All Fire extinguishers are current with service date 03/28/2022. Carbon monoxide and smoke detectors were observed to be operational. First Aid Kit was checked and observed to have the required supplies. Emergency exit plan, phone numbers, and required postings were observed. A working telephone was present.

At this time LIcensing is not completed pre-licensing inspection and LPA will come back once this potential threat resolved. Assisted Living section will work on securing access to chemicals in public laundry room that might be a potential threat to dementia residents.

Component III was reviewed with Licensee and Administrator.

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023
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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