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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 247206921
Report Date: 07/14/2021
Date Signed: 07/14/2021 03:16:52 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
06/22/2021 and conducted by Evaluator Lady Cabrera
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20210622113417
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: 72DATE:
07/14/2021
UNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Tyler Wilds, AdministratorTIME COMPLETED:
11:50 AM
ALLEGATION(S):
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Staff are not answering the call buttons in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Lady Cabrera conducted an unannounced subsequent complaint visit on this date. LPA met with Adminsitrator and stated the purpose of the visit.

During the investigation, LPA interviewed Staff (S1), S2, S3, Resident (R1), and reviewed 5/1/2021-6/23/2021 call button records. R1 reported the facility staff would respond to the call button after an hour and a half. R1 reported they can’t depend on the staff if they have an emergency in assisted living. Upon review of the call buttons records, LPA observed several calls that had delayed response times. LPA interviewed staff and inquired if staff are answering the call buttons in a timely manner. Staff reported they are short staffed and sometimes take 30 to 45 minutes to respond due to assisting other residents or completing other job duties. Based on interviews and review of the records, the preponderance of the evidence standard has been met therefore the above allegation is SUBSTANTIATED. Deficiency cited in the attached LIC9099-D and appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
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 3
Control Number 24-AS-20210622113417
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: 07/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/15/2021
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care...
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Licensee shall submit a plan of correction (POC) by 07/15/2021, that details the steps that will be taken to ensure that resident calls for assistance are responded to in a timely manner. Licensee sttated he is in the process of hiring more staff in the assisted living area.
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This requirement was not met as evidenced by delayed response times to call buttons, which poses an Immediate health and safety risk to residents 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: 07/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20210622113417
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
VISIT DATE: 07/14/2021
NARRATIVE
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An exit interview was conducted, and Plan of Correction (POC) was reviewed and developed with the Administrator. Administrator provided with LIC9099, LIC9099-D and Appeal Rights.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3