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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107209116
Report Date: 06/10/2024
Date Signed: 06/11/2024 08:56:10 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
02/26/2024 and conducted by Evaluator Vadim Gorban
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240226134733
FACILITY NAME:PACIFICA SENIOR LIVING FRESNOFACILITY NUMBER:
107209116
ADMINISTRATOR:RANGEL, EDDIEFACILITY TYPE:
740
ADDRESS:1715 E ALLUVIAL AVENUETELEPHONE:
(559) 298-4900
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:100CENSUS: 57DATE:
06/10/2024
UNANNOUNCEDTIME BEGAN:
12:32 PM
MET WITH:Administrator, Brandon MontelongoTIME COMPLETED:
01:33 PM
ALLEGATION(S):
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Staff did not seek timely medical attention for resident
INVESTIGATION FINDINGS:
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On 06/10/2024, Licensing Program Analyst (LPA) V. Gorban visited the facility to deliver findings. During this visit LPA met with facility Administrator (AD) Brandon Montelongo and stated the purpose of the visit. During this visit LPA toured the facility inside and out and observed residents in care. Once the tour was complete, LPA discussed the findings with the AD.

Allegation: Staff did not seek timely medical attention for resident. Based of staff interviews and record reviews, once staff responded to resident call, assessment was completed on cite by facility nurse and emergency medical services was requested. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.

Report continues on LIC 9099-A
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
02/26/2024 and conducted by Evaluator Vadim Gorban
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240226134733

FACILITY NAME:PACIFICA SENIOR LIVING FRESNOFACILITY NUMBER:
107209116
ADMINISTRATOR:RANGEL, EDDIEFACILITY TYPE:
740
ADDRESS:1715 E ALLUVIAL AVENUETELEPHONE:
(559) 298-4900
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:100CENSUS: 57DATE:
06/10/2024
UNANNOUNCEDTIME BEGAN:
12:32 PM
MET WITH:Administrator, Brandon MontelongoTIME COMPLETED:
01:33 PM
ALLEGATION(S):
1
2
3
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5
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7
8
9
Staff do not respond to resident call buttons in timely manner
INVESTIGATION FINDINGS:
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5
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13
On 06/10/2024, Licensing Program Analyst (LPA) V. Gorban visited the facility to deliver findings. During this visit LPA met with facility Administrator (AD) Brandon Montelongo and stated the purpose of the visit. During this visit LPA toured the facility inside and out and observed residents in care. Once the tour was complete, LPA discussed the findings with the AD.

Allegation: Staff do not respond to resident call buttons in timely manner. Based off interviews and record reviews facility failed to respond to resident call light in timely manner resulting resident laying on the floor for extended period of time. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 being cited on the attached LIC 9099D.
Exit interview conducted, report signed and copy of this report with appeal rights provided to Administrator for facility record.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20240226134733
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
87411(a)
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87411 Personnel Requirements - General,
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This was not observed as evidenced by:
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The facility Administrator will randomly tests call light to observe staff responding in timely manner, Administrator also provided in service training every first Thursday of the month and provide to LPA by email.
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Based on staff interview and records review the facility failed to respond to residents call in timely manner resulted resident laying on the floor bleeding. This is poses a potential health and safety risk to persons 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: 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
LIC9099 (FAS) - (06/04)
Page: 3 of 3