247206921-6-23-2021-24-AS-SPIY-C4NT5U-20210706142607

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 247206921
Report Date: 06/23/2021
Date Signed: 06/23/2021 03:41:37 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
05/19/2021 and conducted by Evaluator Lady Cabrera

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20210519140138

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: 70	DATE:	06/23/2021
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Tyler Wilds, Administrator		TIME COMPLETED:	10:25 AM

ALLEGATION(S):

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Facility did not obtain a medical assessment signed by a physician prior to resident's acceptance.
Facility did not ensure that a current record is maintained for resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Lady Cabrera conducted the subsequent complaint visit. LPA spoke with Administrator Tyler Wilds and delivered investigation findings regarding the above allegations.

This agency has investigated the complaint alleging the above allegations. The Department conducted interviews, and reviewed records. On 04/27/2021, Resident's (R1) Physician’s Report was completed prior to being admitted to the facility on 04/29/2021. Per Physician’s Report, it indicates R1’s Primary and secondary diagnosis, R1’s physical health status, mental condition, capacity for self-care, and ambulatory status. Based on the Physician’s Report and Resident’s Assessment dated 04/28/2021, it determines the level of care and current records for R1. We have found that the complaint was unfounded, therefore we have dismissed the complaint.

Exit Interview was conducted. Administrator was informed that as a COVID-19 precautionary measure, this report will be emailed.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady Cabrera	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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