<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247202428
Report Date: 12/28/2023
Date Signed: 12/29/2023 10:01:56 AM


Document Has Been Signed on 12/29/2023 10:01 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:ELINA MOILANENFACILITY TYPE:
740
ADDRESS:3050 M STREETTELEPHONE:
(209) 722-3944
CITY:MERCEDSTATE: CAZIP CODE:
95348
CAPACITY:125CENSUS: 62DATE:
12/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:James Nordman - Vice President of operationsTIME COMPLETED:
11:05 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12/28/2023, Licesing Program Analyst(LPA) D. Ayers arrived at the facility unannounced to conduct a case management inspection. LPA met with Vice President of Operation James Nordman and announced the purpose of the inspection.

The purpose of the inspection was to follow-up on an incident which occurred on 9/15/2023. On 9/15/2023, Resident 1 (R1) was found across the street from the facility by law enforcement personnel. R1 did not receive any bruising or injuries. On 11/30/2023, facility staff reassessed R1's care needs and adjusted her care level.

Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiency was observed and cited on the attached LIC 809-D. Failure to correct the deficiency may result in civil penalties.
An exit interview was conducted, and a copy of this report provided to the licensee via email. Appeal Rights (LIC 9058) were provided to the licensee.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David AyersTELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 12/29/2023 10:01 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/28/2023
Section Cited
CCR
87464(f)(1)

1
2
3
4
5
6
7
87464 Vasic Services: (f) Basic services shall at a minimum include:
(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
R1 was reassessed by facility staff, and her care level was raised. Auditory alert device has been repaired.
8
9
10
11
12
13
14
Based off of record review, the licensee did not ansure that this requirement was met for at least one out of 62 residents on 9/15/2023, when a resident diagnosed with dementia was found across the street from the facility.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David AyersTELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2