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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209116
Report Date: 12/20/2023
Date Signed: 12/21/2023 03:09:22 PM


Document Has Been Signed on 12/21/2023 03:09 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:
(559) 298-4900
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:100CENSUS: 48DATE:
12/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Administrator, Jeralyn MaiTIME COMPLETED:
01:35 PM
NARRATIVE
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On 12/20/23 at 08:17 AM, Licensing Program Analyst (LPA) V Gorban arrived unannounced to conduct a case management inspection. LPA explained the reason for inspection and met with Administrator (AD) Jeralyn Mai.

LPA toured the facility inside and out to conduct safety checks.

Incident 1: RO received an incident report on 12/15/23 medication error. R1 was given medication in the morning. R1 was provided with the wrong dose of medication. R1 received Clonazepam of 1,0mg. instead of 0.5mg, prescribed by physician.
When interviewed, staff responded they realized error during medication count that conducted every end of the shift which is three times a day.
AD notified regional office (RO) same day by incident report. Responsible Party and physician of R1 was notified same day as well by the facility.

Incident 2: On 12/13/23 RO was notified of R2 official 30-day termination and notice to quit. Notice due date was 12/13/23.
RO was not notified by the facility of R1 eviction. Facility did not follow title 22 states eviction procedures.
Deficiencies are cited on LIC-9099.



Exit interview conducted, report signed and copy of this report with appeal rights provided for facility records.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023
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 12/21/2023 03:09 PM - 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: 12/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/20/2023
Section Cited
CCR
87465(c)(2)

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87465 Incidental Medical and Dental Care.
(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by.
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Following the plan of Correction, Administrator will provide to Regional Office staff training on medication dispense and medical care by 12/20/23. POC was corrected during the visit.
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Based interviews and incident report provided to Regional Office, R1 received a double dose of medication: 1.0mg instead of 0.5mg of Clonazepam prescribed.
This is poses immediate health and safety risk of residents in care.
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Type B
12/22/2023
Section Cited
CCR87224(b)

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87224 Eviction Procedures.
(b) The licensee may, upon obtaining prior written approval from the licensing agency, evict the resident upon three (3) days written notice to quit. The licensing agency may grant approval for the eviction upon a finding of good cause. This was not observed as evidenced by:
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Following the Plan of Correction, Administrator will properly notify Regional Office and LPA by following Title 22 eviction procedures by 12/22/23. POC was corrected during the visit.
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Regional Office was not notified of eviction notice by facility and resident to be evicted from facility when title 22 was not followed which poses health and safety risk of residents 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: 12/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023
LIC809 (FAS) - (06/04)
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