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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600255
Report Date: 08/15/2024
Date Signed: 08/15/2024 01:16:13 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/08/2024 and conducted by Evaluator Gregory Clark
COMPLAINT CONTROL NUMBER: 15-AS-20240808082122
FACILITY NAME:MERCY RETIREMENT & CARE CENTERFACILITY NUMBER:
015600255
ADMINISTRATOR:DAVIS, JOSEPHINE IFACILITY TYPE:
741
ADDRESS:3431 FOOTHILL BOULEVARDTELEPHONE:
(510) 534-8540
CITY:OAKLANDSTATE: CAZIP CODE:
94601
CAPACITY:160CENSUS: 74DATE:
08/15/2024
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Elvira Suciu, Resident Care DiectorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff do not ensure that resident's dietary needs are met
Staff are not following resident's feeding plan
INVESTIGATION FINDINGS:
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On 8/15/24 at 11:30 a.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation in regard to the allegations above. LPA met with Elvira Suciu, Resident Care Diector and explained the purpose of the visit.

During the course of the investigation LPA interviewed the Reporting Party (RP) and S1. LPA also reviewed R1’d file and observed R1 in her room.

R1 was admitted to the facility on 9/02/23 on hospice. R1 has a diagnosis of Parkinsonism and unspecified dementia. R1’s diet is prescribed as “thickened to a honey consistency.” LPA observed thickened liquids in R1’s room and in her refrigerator. Currently R1 has difficulty swallowing, pocking food and is on aspiration precaution. S1 stated that R1’s condition has been declining slowly since her admission.

***report continues on LIC9099C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
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 2
Control Number 15-AS-20240808082122
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 08/15/2024
NARRATIVE
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***report continues from LIC9099***

Allegation: Staff do not ensure that resident's dietary needs are met.

Based on file review, observation and interviews this allegation is unsubstantiated.

Allegation: Staff are not following resident's feeding plan.

Based on file review, observation and interviews this allegation is unsubstantiated.

This agency has investigated the complaint alleging staff do not ensure that resident's dietary needs are met and staff are not following resident's feeding plan. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted, a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2