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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107209116
Report Date: 02/16/2024
Date Signed: 02/17/2024 11:37:25 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
11/17/2023 and conducted by Evaluator Vadim Gorban
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20231117151834
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: 74DATE:
02/16/2024
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator, Jeralyn MaiTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is not properly treating for cockroaches.
Facility floor surfaces are not maintained in an odorless condition.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 2/16/24 Licensing Program Analyst (LPA) Gorban conducted subsequent visit to deliver findings.
LPA met with Administrator, Jeralyn Mai and stated purpose of the visit.

Allegations: Facility is not properly treating for cockroaches and Facility floor surfaces are not maintained in an odorless condition.
During the course of investigation LPA conducted interviews and record reviews. 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 allegations are Unsubstantiated.

Exit interview conducted, report signed and copy of this report provided to AD for facility records.
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: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
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
11/17/2023 and conducted by Evaluator Vadim Gorban
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20231117151834

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: 74DATE:
02/16/2024
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator, Jeralyn Mai.TIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility floor surfaces are not maintained in a clean condition.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 2/16/24 Licensing Program Analyst (LPA) Gorban conducted subsequent visit to deliver findings.
LPA met with Jeralyn Mai and stated purpose of the visit.

Allegation: Facility floors are not maintained in a clean condition. During the course of the investigation, LPA conducted interviews and records reviews. Based on previous LPAs observations and records reviews which were conducted previously revealed that the facility does not have scheduled floor maintenance, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Deficiency cited on the attached 9099 D

Exit interview conducted, report signed and copy of this report with appeal rights provided to AD for facility records.
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: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
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-20231117151834
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: 02/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/20/2024
Section Cited
CCR
87303(a)
1
2
3
4
5
6
7
87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents.
This was not observed as evidenced by:


1
2
3
4
5
6
7
Administrator provided plan of correction to carpet cleaning schedule and maintenance, including independent and assisting living portion of the facility. Dining room and facility main entrance washed monthly, every couple months facility cleaning facility hallways.
8
9
10
11
12
13
14
Based on observations and interviews staff did not have scheduled floors maintenance, floors with spots on carpet floors of dirt all over the facility, which poses potential health and safety risk to residents 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: 02/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3