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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 247206921
Report Date: 11/17/2020
Date Signed: 11/17/2020 03:18:11 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/06/2020 and conducted by Evaluator Dixie Marie Wright
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20200306144542
FACILITY NAME:PACIFICA SENIOR LIVING MERCEDFACILITY NUMBER:
247206921
ADMINISTRATOR:WILLIAMSON, PAIGEFACILITY TYPE:
740
ADDRESS:3420 R STTELEPHONE:
(209) 436-7259
CITY:MERCEDSTATE: CAZIP CODE:
95348
CAPACITY:93CENSUS: 75DATE:
11/17/2020
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Tyler WildsTIME COMPLETED:
11:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff is mismanaging resident's medications.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) D.Wright contacted the facility to commence a complaint investigation via telephone due to COVID-19 and pre-cautionary measures. LPA discussed the purpose of the call and the elements of the allegation with Administrator Tyler Wilds. (Note: This complaint and the findings were in March through June of 2020; Tyler was not Administrator at the time of the complaint).

During the course of the investigation, records were reviewed and interviews were conducted. Based on records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. In March, LPA counted a sample of resident's medications, and according to the start date, medications had not been dispensed correctly. See citation on the attached LIC. 9099D.
Appeal rights given.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Dixie Marie WrightTELEPHONE: (559) 772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 24-AS-20200306144542
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PACIFICA SENIOR LIVING MERCED
FACILITY NUMBER: 247206921
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/17/2020
Section Cited
CCR
87465(c)(2)
1
2
3
4
5
6
7
Incidental Medical and Dental Care Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Licensee failed to
1
2
3
4
5
6
7
Per Tyler, the facility now has a nurse in the building. She oversees the medications in the Assisted Living side and Memory Care side. They have had multiple trainings on medications. They have an outside
8
9
10
11
12
13
14
administer medications according to physician's directions. This poses an immediate risk to the residents in care.
8
9
10
11
12
13
14
company audit the medications. They also are going to electronic Medication Administration Records in January. Procedures have been put in place to prevent medication errors; deficiency cleared.
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: Melinda HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Dixie Marie WrightTELEPHONE: (559) 772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2