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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600255
Report Date: 09/15/2021
Date Signed: 09/15/2021 12:25:42 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:MERCY RETIREMENT & CARE CENTERFACILITY NUMBER:
015600255
ADMINISTRATOR:TAMRA MARIE TSANOSFACILITY TYPE:
741
ADDRESS:3431 FOOTHILL BOULEVARDTELEPHONE:
(510) 534-8540
CITY:OAKLANDSTATE: CAZIP CODE:
94601
CAPACITY:160CENSUS: 67DATE:
09/15/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Tamra Marie Tsanos, AdministratorTIME COMPLETED:
12:45 PM
NARRATIVE
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On 9/15/2021 at 11:15AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Case Management Inspection in regards to an incident report received on 9/2/2021. LPA met with Administrator, Tamra Marie Tsanos.

Incident report reveal that R1 was given incorrect dosage of Hydrocodone than the physician's order.

Interview with S1, S2, and S3 revealed that the physician's order two different dosage for Hydrocodone with one being a PRN medication. It was discovered that PRN medication have been given incorrectly to R1. S2 stated that facility have implemented new procedures and guidelines for medication administration. Disciplinary action was given to the staff that was involved. Routine audits of medication have been implemented and staff will be provided refresher course related to medication administration.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 . Failure to correct deficiency may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MERCY RETIREMENT & CARE CENTER
FACILITY NUMBER: 015600255
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/27/2021
Section Cited

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Incidental Medical and Dental Care Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidence by:
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Based on record review and interview, licensee did not comply with the section cited above by dispensing the incorrect dosage to R1 which poses a potential health and safety risk to the residents in care.
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 or implemenation to CCLD by POC date.

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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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2021
LIC809 (FAS) - (06/04)
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