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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247206921
Report Date: 06/09/2021
Date Signed: 06/09/2021 02:06:48 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 MERCEDFACILITY NUMBER:
247206921
ADMINISTRATOR:TYLER WILDSFACILITY TYPE:
740
ADDRESS:3420 R STTELEPHONE:
(209) 580-6124
CITY:MERCEDSTATE: CAZIP CODE:
95348
CAPACITY:93CENSUS: 70DATE:
06/09/2021
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
01:43 PM
MET WITH:Tyler Wilds, AdministratorTIME COMPLETED:
02:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lady Cabrera conducted a subsequent Case Management (CM) visit to discuss information obtained from CM visit conducted on 05/26/2021.


The purpose of the visit is to address the incident that occurred on 03/23/2021 Unusual incident report was submitted to CCLD by the facility staff. The incident that occurred on 03/23/2021 resulted in resident R1 going absent without leave (AWOL). Facility Staff received a call from unknown caller indicating R1 was walking away from the facility. Staff immediately went outside to redirect R1.

The following deficiencies were observed and noted on the attached LIC 809D. All violations that, if not corrected, will have direct and immediate risk to the health, safety or personal rights of clients in care.

Exit interview conducted with Administrator and was provided with the LIC809, LIC809-D and Appeal Rights.

SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/10/2021
Section Cited

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ยง1569.312 Basic services requirements

Every facility required to be licensed under this chapter shall provide at least the following basic services:
(a) Care and supervision as defined in Section 1569.2.

*This requirement was not met as evidenced by:

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The incident occurred on 03/21/2021 resulted in resident R1 going AWOL from the facility. R1 is/was unable to leave the facility unassisted per Physician Report dated 5/8/2019. Resident has a dementia diagnosis.This presents an immediate risk to the health, safety or personal rights of the clients in care.
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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: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2021
LIC809 (FAS) - (06/04)
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