247206921-2-10-2021-24-AS-LCAA-BY52BR-20210210161533

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 247206921
Report Date: 01/28/2021
Date Signed: 02/10/2021 04:15:38 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR:	TYLER WILDS		FACILITY TYPE:	740
ADDRESS:	3420 R ST		TELEPHONE:	(209) 580-6124
CITY:	MERCED	STATE: CA	ZIP CODE:	95348
CAPACITY:	93	CENSUS: 69	DATE:	01/28/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Tyler Wilds, Administrator		TIME COMPLETED:	11:30 AM

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Licensing Program Analyst (LPA) Lady Cabrera contacted Tyler Wilds, Administrator by phone due to COVID-19 and pre-cautionary measures.

On 1/27/2021, Community Care Licensing received the Unusual Incident/Injury Report that occurred on 1/21/2020. The purpose of the phone call is to follow-up on the health and safety check of the residents and to obtain additional information.

LPA requested the following documents and records:

1. Resident’s Admission Agreement

2. LIC602A

3. Staff contact information

4. Police Report case number

An exit interview was conducted with the Administrator and a copy of this report was provided via email.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady Cabrera	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2021

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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