107209116-5-2-2024-24-AS-BCHN-D5CUHC-20240517153543

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107209116
Report Date: 04/30/2024
Date Signed: 05/02/2024 05:22:42 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
02/07/2024 and conducted by Evaluator Vadim Gorban

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20240207152206

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: 61	DATE:	04/30/2024
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Administrator Brandon Montelongo		TIME COMPLETED:	10:40 AM

ALLEGATION(S):

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7
8
9

Staff are not providing adequate food service

INVESTIGATION FINDINGS:

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5
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7
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13

On 4/30/2024, 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 are not providing adequate food service. During complaint investigation the LPA reviewed facility records, interviewed facility staff, residents, and the Administrator. Based of observations, interviews and records review no violations have been observed. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

Report continues on LIC9099-A
Exit interview conducted, report signed and copy of this report provided to the Administrator.

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: 04/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024

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
02/07/2024 and conducted by Evaluator Vadim Gorban

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20240207152206

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: 61	DATE:	04/30/2024
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Administrator, Brandon Montelongo		TIME COMPLETED:	10:40 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not store food properly

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 4/30/2024, 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.

Allegation: Staff do not store food properly

During this complaint investigation LPA observed food storage equipment, reviewed facility files, and interview staff and residents. Based on LPA observation the facility stored food did not have date on it. Based on interviews conducted, records reviewed and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 & Chapter 8, is being cited on the attached LIC 9099-D.

Exit interview conducted, report signed and copy with the appeal rights provided to Administrator for records.

Substantiated

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: 04/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024

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-20240207152206

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: 04/30/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/03/2024 Section Cited CCR 87555(b)(9)	1 2 3 4 5 6 7	87555 General Food Service Requirements (b) (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This was not observed as evidenced by:	1 2 3 4 5 6 7	The facility corrected deficiency during the visit by tossing out the perishable food from the refrigerator with no dates on it. Administrator will provided kitchen staff training to LPA by email.
	8 9 10 11 12 13 14	The facility failed to follow regulation cited above. The prepared perishable food when stored in the refrigerator was not dated, that 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 Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim Gorban	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024

LIC9099 (FAS) - (06/04)

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