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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209116
Report Date: 06/10/2024
Date Signed: 06/11/2024 08:45:41 AM


Document Has Been Signed on 06/11/2024 08:45 AM - 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:MONTELONGO, BRANDONFACILITY TYPE:
740
ADDRESS:1715 E ALLUVIAL AVENUETELEPHONE:
(559) 298-4900
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:100CENSUS: 57DATE:
06/10/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator Brandon MontelongoTIME COMPLETED:
03:10 PM
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
On 06/10/24, Licensing Program Analyst (LPA) V Gorban conducted a case management deficiency visit to the facility. LPA introduced self, stated the purpose of the visit, and met with Administrator Brandon Montelongo.

The purpose of the visit is to address an incident that occurred where R1 went AWOL on 03/03/2024.
The facility was unaware when R1 AWOL the facility. The facility staff unaware of how long R1 was outside. Residents file review stated resident unable to leave facility unassisted.

Therefore, as a result, a deficiency is being cited, per California Code of Regulations, Title 22, Division 6, see attached 809D.

An exit interview was conducted. A copy of this report and appeal rights provided to Administrator, whose signature confirms receipt of this report.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 06/11/2024 08:45 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 FRESNO
FACILITY NUMBER: 107209116

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/14/2024
Section Cited
CCR
87413(a)(2)

1
2
3
4
5
6
7
87413 Personnel - Operations. (2) Care and supervision of residents shall be provided without physical or verbal abuse, exploitation or prejudice. This was not observed as evidenced by:
1
2
3
4
5
6
7
Administrator will routine checks for elopement of residents staff hourly especially during evening and NOC shifts. In-service training is complete and will be provided to LPA by email.
8
9
10
11
12
13
14
The facility failsed to provide supervision resulted unsupervised dementia resident found outside laying on the ground with pillow, blanket, and remote control. This is poses potential health and safety risk to persons in care.
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: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2