107209116-4-29-2024-24-AS-BCHN-D5D27S-20240517170910

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107209116
Report Date: 04/25/2024
Date Signed: 04/29/2024 08:25:44 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
02/02/2024 and conducted by Evaluator Vadim Gorban

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20240202114450

FACILITY NAME:	PACIFICA SENIOR LIVING FRESNO		FACILITY NUMBER:	107209116
ADMINISTRATOR:	RANGEL, EDDIE		FACILITY TYPE:	740
ADDRESS:	1715 E ALLUVIAL AVENUE		TELEPHONE:	(559) 298-4900
CITY:	FRESNO	STATE: CA	ZIP CODE:	93720
CAPACITY:	100	CENSUS: 62	DATE:	04/25/2024
		UNANNOUNCED	TIME BEGAN:	08:48 AM
MET WITH:	Resident Services Director, Rupinder Singh		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff do not ensure the dishes are cleaned properly
Staff are not serving residents food in a sanitary manor

INVESTIGATION FINDINGS:

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On 4/25/24, Licensing Program Analyst (LPA) V. Gorban visited the facility to deliver findings. During this visit LPA met with facility with Resident Services Director (RSD) Rupinder Singh 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 RSD

Allegation: Staff do not ensure the dishes are cleaned properly. During complaint investigation the department Toured the facility for observations, interviewed facility staff and the Administrator. Based of observations, records review and staff interview the dishes cleaned by machine and no concerns of dirty dishes observed by kitchen personnel. 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.

Report continues on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim Gorban	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 24-AS-20240202114450

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
	VISIT DATE: 04/25/2024

NARRATIVE

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Allegation: Staff are serving residents food in sanitary manor. During complaint investigation LPA toured the facility for observations, interviewed facility residents, and kitchen staff. Based of observation conducted on 2/6/24 and kitchen staff and residents interview staff follow hand hygiene before serving residents with kitchen utensils to deliver food. 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 RSD for facility records.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim Gorban	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

LIC9099 (FAS) - (06/04)

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