015600255-5-22-2025-15-AS-YFLS-DHBMHB-20250604093713

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015600255
Report Date: 05/22/2025
Date Signed: 05/22/2025 03:02:40 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
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:	03:00 PM
MET WITH:	Kathleen McCarron, Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

1
2
3
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7
8
9

Questionable death

INVESTIGATION FINDINGS:

1
2
3
4
5
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7
8
9
10
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12
13

On 05/22/2025 at At, 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 the W1, facility staff, facility residents, hospice staff and W2. The department also reviewed R1’s medical records. Review of R1's medical records and death certificate revealed that R1’s cause of death was metastatic prostate cancer. R1 was diagnosed with prostate cancer in 2008.

The department has investigated the complaint alleging questionable death. 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: 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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