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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247206921
Report Date: 04/17/2025
Date Signed: 04/25/2025 02:08:25 PM

Document Has Been Signed on 04/25/2025 02:08 PM - 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/
DIRECTOR:		EMILY VENEGASFACILITY TYPE:
740
ADDRESS:3420 R STTELEPHONE:
(209) 580-6124
CITY:MERCEDSTATE: CAZIP CODE:
95348
CAPACITY: 93TOTAL ENROLLED CHILDREN: 0CENSUS: 75DATE:
04/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:administrator Lisa BaricevicTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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On 04/17/2025, Licensing Program Analyst (LPA) V Gorban arrived at the facility unannounced to conduct Required Annual Inspection. LPA met with Administrator (AD) Lisa Baricevic. LPA conducted tour inside and out of facility with AD. Residents observed at the facility during lunch time.

The facility was observed to be at a comfortable temperature of 76 degrees, clean, in good repair, and no passageway obstructions or fire hazards observed. Fire extinguisher was observed with a service date of 05/06/2024
Dining area and Kitchen were toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in freezer, refrigerator, and pantry. Food is delivered by US Foods twice a week on Mondays and Thursdays. Refrigerator temperature was maintained at 39.0-degree F. and freezer was maintained at -10-degree F.
Residents' rooms were toured and observed with adequately furnished with bed, dresser, and adequate lighting. Hot water temperature tested and recorded at 105-degree F. LPA observed securely fastened grab bar and non-skid mat in shower area.

Medications were stored in a locked medication room in a medication cart and monitored by QuickMar. Medications records were reviewed. First Aid Kit was stored in medication room and observed with all required items. LPA toured laundry room and observed chemicals were stored and locked for staff use only.
Facility courtyard was toured and observed to be free from debris. There was outdoor seating available for the residents.

Report continues on attached LIC809-C

Brenda ChanTELEPHONE: (650) 266-8889
Vadim GorbanTELEPHONE: (559) 243-8080
DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 MERCED
FACILITY NUMBER: 247206921
VISIT DATE: 04/17/2025
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Residents’ files were reviewed to have updated emergency contact, Admission agreement, Needs and Services Plan and Pre-Appraisal Plan. A sample of staff files were reviewed. Staff files were observed to have current First Aid/CPR, Health screening, and Personnel record. Staff are fingerprinted clear and associated to the facility.
Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below:

Residential Care Facility for the Elderly (RCFE):


· LIC 308 Designation of Facility Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly


Please submit the above forms/information to Fresno CCL by: 04/27/2025

As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed.


The observed deficiency was cited during case management visit.
An exit interview was conducted with the AD.

A copy of this report was given to the AD with appeal rights, whose signature on this form confirm receipt of these reports.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/25/2025 02:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 MERCED
FACILITY NUMBER: 247206921

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87456(a)(3)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/27/2025
Plan of Correction
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The facility administrator will review and update resident physician report and provide a copy of updated report to Licensing office or LPA by OC due date. Plan of correction will be recorded during case management visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Brenda ChanTELEPHONE: (650) 266-8889
Vadim GorbanTELEPHONE: (559) 243-8080

DATE: 04/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2025

LIC809 (FAS) - (06/04)
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