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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247206921
Report Date: 10/17/2024
Date Signed: 10/17/2024 11:10:25 AM


Document Has Been Signed on 10/17/2024 11:10 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:PACIFICA SENIOR LIVING MERCEDFACILITY NUMBER:
247206921
ADMINISTRATOR:EMILY VENEGASFACILITY TYPE:
740
ADDRESS:3420 R STTELEPHONE:
(209) 580-6124
CITY:MERCEDSTATE: CAZIP CODE:
95348
CAPACITY:93CENSUS: 71DATE:
10/17/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Executive Director - Emily VenegasTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) M Vega arrived unannounced to conduct a Case Management visit on 10/17/2024 at 10:40 AM. LPA met with facility Front Desk staff, LPA introduced self and presented badge. Front Desk staff obtained contact with Executive Director Emily Venegas. Stated the purpose of visit to Executive Director.

LPA served Decision and Order excluding Staff 1 (S1) from being present inside the facility. LPA requested a current and updated Personnel Report (LIC 500) and Guardian account be updated to remove S1 from the facility staff roster. A notice of completion shall be submitted to Community Care Licensing (CCL).

LPA informed Executive Director Emily Venegas that S1 is not allowed to be employed and/or on any facility premises. The Decision and Order of Exclusion From All Facilities came into effect as of 05/31/2024 upon receipt of the letter. A copy of the letter was given to facility Executive Director Emily Venegas during this visit.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed and cited. Exit interview held with Executive Director Emily Venegas, A Copy of report given.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 272-4781
LICENSING EVALUATOR NAME: Martin VegaTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024
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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