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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600255
Report Date: 06/19/2024
Date Signed: 06/19/2024 03:00:05 PM

Unfounded


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
06/17/2024 and conducted by Evaluator Gregory Clark
COMPLAINT CONTROL NUMBER: 15-AS-20240617122846
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: 77DATE:
06/19/2024
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Josephine Davis, AdministratorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff unlawfully evicted a resident
Staff did not meet a resident's oxygen needs
Staff mishandled a resident's personal belonging
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 6/19/24 at 2:20 p.m., Licensing Program Analysts (LPAs) Greg Clark and A. Gharachorloo arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegations above. LPA met with Josephine Davis, Administrator and explained the purpose of the visit.

LPAs interviewed S1 who stated R1 lives in the Mercy Retirement & Care Center’s Skilled Nursing Facility(SNF). He does not live in the building licensed by CCL. LPAs reviewed resident rosters of both facilities and found R1 on the roster for the SNF.

This agency has investigated this complaint. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview conducted, a copy of this report provided.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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