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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247206921
Report Date: 12/28/2023
Date Signed: 12/29/2023 09:59:08 AM


Document Has Been Signed on 12/29/2023 09:59 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 MERCEDFACILITY NUMBER:
247206921
ADMINISTRATOR:DANIEL GORMLEYFACILITY TYPE:
740
ADDRESS:3420 R STTELEPHONE:
(209) 580-6124
CITY:MERCEDSTATE: CAZIP CODE:
95348
CAPACITY:93CENSUS: 70DATE:
12/28/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Emily Venegas - Executive Director TIME COMPLETED:
11:55 AM
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On 12/28/2023, Licensing Program Analyst(LPA) D. Ayers arrived unannounced to conduct a case management inspection. LPA met with Executive Director Emily Venegas and announced the purpose of the inspection.

LPA conducted a tour of the facility to ensure that there were no immediate health or safety concerns. LPA requested additional information regarding an incident which occurred 12/19/2023. No deficiencies were cited during the inspection. Exit interview conducted, and a copy of the report was provided to the licensee.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David AyersTELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023
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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