015600255-5-22-2025-15-AS-YFLS-DHBMHC-20250604093714

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015600255
Report Date: 05/22/2025
Date Signed: 05/22/2025 03:01:36 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
04/10/2024 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20240410105909

FACILITY NAME:	MERCY RETIREMENT & CARE CENTER		FACILITY NUMBER:	015600255
ADMINISTRATOR:	DAVIS, JOSEPHINE I		FACILITY TYPE:	741
ADDRESS:	3431 FOOTHILL BOULEVARD		TELEPHONE:	(510) 534-8540
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94601
CAPACITY:	160	CENSUS: 78	DATE:	05/22/2025
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Kathleen McCarron, Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff did not administer medications as prescribed.
Staff did not inform resident's responsible party of incidents in a timely manner.

INVESTIGATION FINDINGS:

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On 05/22/2025 at 2:30 pm, Licensing Program Analysts (LPAs) Greg Clark and Ardalan Gharachorloo arrived unannounced to deliver findings in regard to the allegations above. LPA met with Kathleen McCarron, Administrator and explained the purpose of the visit.

During the course of the investigation the department interviewed W1, facility staff, facility residents, hospice staff and W2. The department also reviewed R1’s medical records.

R1 was admitted to the facility on 12/28/23 because his health was deteriorating due to prostate cancer. R1 was on hospice at time of admission.

Allegation: staff did not administer medications as prescribed
LPA reviewed R1’s medication administration records (MARs) for March and April 2024. MARs revealed that R1 was prescribed a total of 9 medications that were to be given as needed (PRN) for pain, anxiety, restlessness vomiting and constipation.

***CONTINUE ON 9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

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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Control Number 15-AS-20240410105909

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: 05/22/2025

NARRATIVE

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***CONTINUE FROM 9099***

R1 was also prescribed a daily aspirin. LPA observed that the PRN medications were all signed off as administered by the hospice nurses. From 4/01/24 until the time of R1’s passing on 4/10/24 he was given a total of 22 PRN medications for pain, restlessness, and anxiety. LPA observed that the MARs for the PRN medications were filled out according to regulation.

Allegation: staff did not inform residents responsible party of incidents in a timely manner

The department interviewed W2. W2 stated that she visited R1 regularly at the facility. W2 had no complaints regarding facility staff stating staff took care of R1 and provided him with sufficient supervision. W2 further stated that staff always instructed R1 to be careful when walking and would check on R1 all the time.

LPA was unable to reach the W1 or W2 for further investigation as which incidents weren’t reported in a timely manner.

This agency and the department have investigated the complaints alleging staff did not administer medications as prescribed, and staff did not inform residents responsible party of incidents in a timely manner. We have found that the allegations were unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted, a copy of this report provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

LIC9099 (FAS) - (06/04)

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