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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209116
Report Date: 02/07/2023
Date Signed: 11/08/2023 09:15:49 AM


Document Has Been Signed on 11/08/2023 09:15 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:RANGEL, EDDIEFACILITY TYPE:
740
ADDRESS:1715 E. ALLUVIAL AVENUETELEPHONE:
(619) 296-9000
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:100CENSUS: 78DATE:
02/07/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:Administrator, Eddie RangelTIME COMPLETED:
10:30 AM
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On 02/07/2023, Licensing Program Analyst (LPA) V Gorban made subsequent visit for Unannounced Pre-licensing inspection to the facility stated above. LPA met with administrator Eddie Rangel.

LPA toured the facility.
Facility’s potential threat has been addressed. Facility educated staff and residents. Notice will be posted in public laundry room not to leave washing detergent unattended.

Licensee/Administrator completed Component III Orientation. Pre-Licensing is complete, and this facility has no deficiencies. A copy of this report was provided to the licensee.

All pre-licensing requirements have been met. LPA will notify CAB in Sacramento for final review prior to license being issued.

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023
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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