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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 11:11:52 AM



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
04/29/2021 and conducted by Evaluator Lady Cabrera
COMPLAINT CONTROL NUMBER: 24-AS-20210429103148
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:
10:26 AM
MET WITH:Tyler Wilds, AdministratorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Resident fell multiple times while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Lady Cabrera conducted an unannounced subsequent complaint visit on this date. LPA met with Administrator Tyler Wilds and stated the purpose of the visit.

Based on interviews conducted and records review, resident's fall was not because of lack of care or supervision, and the allegation is UNFOUNDED. R1 had witnessed and unwitnessed falls and was provided immediate evaluation and assistance by facility staff.
Unfounded
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 4
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
04/29/2021 and conducted by Evaluator Lady Cabrera
COMPLAINT CONTROL NUMBER: 24-AS-20210429103148

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:
10:26 AM
MET WITH:Tyler Wilds, AdministratorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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9
Staff did not administer residents medication
INVESTIGATION FINDINGS:
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On 04/22/2021, at 3:05a.m., R1 fell attempting to sit down and missed the chair. R1 was transported to the hospital for evaluation. On the same date, per facility records, at 9:30a.m., R1 returned to the facility. Based on records reviewed, dated 04/22/2021 at 12:17p.m., it indicates R1 was “out of the community.” Staff did not administer resident’s medication, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Per facility’s medication policy, Medications may be given up to one before or up to one hour after the prescribed time to accommodate resident schedules.

Based on the LPAs records review, the Licensee did not meet California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87465(c)(2) Incidental Medical and Dental Care. Deficiency is being cited on the attached LIC 9099-D. A previous licensing report was issued on 05/05/2021 giving notice of the same violation. Civil Penalty in the amount of $250.00 is assessed.
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: 2 of 4
Control Number 24-AS-20210429103148
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
87465(c)(2)
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87465 Incidental Medical...(c)...physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication...(2)Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidenced by:
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Licensee shall submit a plan of correction (POC) by 07/15/2021. POC shall include medication training to all staff that are involved in passing medications to the residents when they return from the hospital. Licensee shall submit a signed training roster to CCLD with a copy of the policy and list of attendees by 07/16/2021.
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Based on records review, the Licensee did not meet the Incidental Medical Care. R1 missed her prescribed medications on 4/22/2021, which poses an Immediate Health, Safety and Personal Rights risks to persons 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: 3 of 4
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
04/29/2021 and conducted by Evaluator Lady Cabrera
COMPLAINT CONTROL NUMBER: 24-AS-20210429103148

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:
10:26 AM
MET WITH:Tyler Wilds, AdministratorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not send residents medication list with her to the hospital
INVESTIGATION FINDINGS:
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Per staff and third-party interviews, it was discovered that all parties interviewed with regards to this allegation (Staff did not send residents medication list with her to the hospital) gave statements that assert the opposite version of occurred events resulting in the provided statements being in conflict with each other. Based on the information obtained from interviews, it was not possible to determine that these allegations had occurred as specified in the complaint. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted, and Plan of Correction (POC) was reviewed and developed with the Administrator. Administrator provided with LIC9099, LIC9099-D, LIC 421FC, and Appeal Rights.
Unsubstantiated
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: 4 of 4