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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247202428
Report Date: 03/20/2025
Date Signed: 03/24/2025 11:53:22 AM

Document Has Been Signed on 03/24/2025 11:53 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:PARK MERCEDFACILITY NUMBER:
247202428
ADMINISTRATOR/
DIRECTOR:		ELINA MOILANENFACILITY TYPE:
740
ADDRESS:3050 M STREETTELEPHONE:
(209) 722-3944
CITY:MERCEDSTATE: CAZIP CODE:
95348
CAPACITY: 125TOTAL ENROLLED CHILDREN: 0CENSUS: 76DATE:
03/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Resident Care Director Mani SongoimoliTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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On 03/20/2025, Licensing Program Analyst (LPA) V Gorban arrived at the facility unannounced to conduct Required Annual Inspection. LPA met with Resident Care Director (RCD) , Mani Songoimoli. Administrator Elina Moilanen was notified of Licensing visit but was not able to attend it, certification number 6053116740 and expiration date 07/31/2025. LPA conducted tour inside and out of facility with RCD. Residents observed at the facility during quite time resting after lunch.
The facility was observed to be at a comfortable temperature of 69 degrees, clean, and no passageway obstructions or fire hazards observed. Fire extinguisher was observed with a service date of 10/10/2024. Last fire drill conducted on 12/20/2023 prior and last one on 11/21/2024. Evacuation drill conducted on 1/31/2025
Dining area and Kitchen were toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in freezer, refrigerator, and pantry. Food is delivered twice a week on Mondays and Wednesdays. Refrigerator temperature was maintained at 42.0-degree F. and freezer was maintained at positive 5-degree F.
LPA toured resident bedrooms. Residents' rooms were toured and observed with adequately furnished with bed, dresser, and adequate lighting. Hot water temperature tested at 109 degrees F. LPA observed securely fastened grab bar and non-skid mat built-in shower area.
Medications were stored in a locked medication room in a medication cart. Medications records were reviewed. First Aid Kit was stored in medication room and observed with all required items. Medications monitored by two medication techs on AM and PM shifts, one med tech during NOC shift by Alis system.
LPA toured laundry room and observed chemicals were stored and locked for staff use only. Secondary laundry room available to residents to use with no chemicals provided.
Facility courtyard was toured and observed to be free from debris. There was outdoor seating available for the residents.

Report continues on attached LIC9099-C

Brenda ChanTELEPHONE: (650) 266-8889
Vadim GorbanTELEPHONE: (559) 243-8080
DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: PARK MERCED
FACILITY NUMBER: 247202428
VISIT DATE: 03/20/2025
NARRATIVE
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Residents and staff files were reviewed.

Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below:

Residential Care Facility for the Elderly (RCFE):


· LIC 308 Designation of Facility Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 9020 Register of Facility Clients/Residents


Please submit the above forms/information to Fresno CCL by: 03/25/2025

As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed.


Exit interview was conducted with the ED.

A copy of this report was given to the ED, whose signature on this form confirm receipt of these reports.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 03/24/2025 11:53 AM - It Cannot Be Edited


Created By: Vadim Gorban On 03/20/2025 at 02:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PARK MERCED
FACILITY NUMBER: 247202428

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(4)
Personal Accommodations and Services
(4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. Outside pation had unlocked doors and alarm not working when door opens. Concete path demolished and no warning signs in place
POC Due Date: 03/25/2025
Plan of Correction
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Facility will provide plan of correction to LPA by email by POC due date
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. Incomplete facility files: emergency disaster and plan of operations.
POC Due Date: 03/25/2025
Plan of Correction
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Facility will provide plan of correction to LPA by email by POC due date
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:Brenda Chan
TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME:Vadim Gorban
TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/24/2025 11:53 AM - It Cannot Be Edited


Created By: Vadim Gorban On 03/20/2025 at 02:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PARK MERCED
FACILITY NUMBER: 247202428

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)
Incomlete file, reviewed both facility binders, Red bindr in med room and white/grey binder AD room, both incomplete upon review: missing LTCO and CVRC contacts, missing two locations for alternative stay, missing transportation details during disatser, etc

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2025
Plan of Correction
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Facility will provide plan of correction to LPA by email by POC due date
Type B
Section Cited
HSC
1569.695(a)(5)
Only one alternative location provided: Bethel Retirement, no second location recorded

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2025
Plan of Correction
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2
3
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Facility will provide plan of correction to LPA by email by POC due date
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:Brenda Chan
TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME:Vadim Gorban
TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 03/24/2025 11:53 AM - It Cannot Be Edited


Created By: Vadim Gorban On 03/20/2025 at 02:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PARK MERCED
FACILITY NUMBER: 247202428

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)(2)

No description of food stored during any kind and type of disasters mentioned in a plan
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2025
Plan of Correction
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2
3
4
Facility will provide plan of correction to LPA by email by POC due date
Type B
Section Cited
HSC
1569.695(a)(4)(D)


This requirement is not met as evidenced by:
Deficient Practice Statement
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§1569.695 (a) (4) Incomplete Emergency Plan: no ombudsman contact, no transportation
POC Due Date: 03/25/2025
Plan of Correction
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2
3
4
Facility will provide plan of correction to LPA by email by POC due date
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:Brenda Chan
TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME:Vadim Gorban
TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2025


LIC809 (FAS) - (06/04)
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