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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 247206921
Report Date: 08/09/2021
Date Signed: 08/09/2021 03:11:35 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
07/14/2021 and conducted by Evaluator Lady Cabrera
COMPLAINT CONTROL NUMBER: 24-AS-20210714114514
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: 77DATE:
08/09/2021
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Tyler Wilds, AdministratorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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The resident was not given the opportunity to read and participate in the development of the pre appraisal.
Resident is sleeping in her chair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Lady Cabrera conducted an unannounced subsequent complaint visit to the facility. During this visit LPA delivered investigation findings regarding the above allegations.
During the course of this complaint investigation LPA interviewed facility staff, obtained and reviewed facility records. It was determined based on the interviews and records reviews that the above allegation is SUBSTANTIATED. On 04/28/2021, Resident’s (R1) Pre-Admission Appraisal assessment was completed by facility staff and R1’s relative only. R1 did not participate in the development of the pre-appraisal.

Based on the interviews, observations, and records review the second allegation is SUBSTANTIATED. It was determined R1 sleeps on her recliner at night due to not getting appropriate assistance.
The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED, are being cited on the attached LIC 9099D.


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: 08/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021
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-20210714114514
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: 08/09/2021
NARRATIVE
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Administrator was informed that as a COVID-19 precautionary measure, LIC809, LIC809-D and Appeal Rights will be emailed to the Administrator.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20210714114514
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: 08/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/23/2021
Section Cited
CCR
87457(a)
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87457 Pre-Admission Appraisal - General(a) Prior to admission, the prospective resident and his/her responsible person, if any, shall be interviewed by the licensee or the employee responsible for facility admissions.

This requirement was not met as evidenced by:
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Licensee shall submit a Plan of Correction (POC) by 08/23/2021, a written plan to have the prospective resident and/his her responsible person particpate in the Pre-Admission Appraisal. Licensee stated a reassement will be completed with the resident.
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Based on interview and records, the Licensee did not ensure that on 04/28/2021, Resident (R1) R1 did not participate in the development of the pre-appraisal, which poses a potential health and safety risk to persons in care.
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Type B
08/23/2021
Section Cited
CCR
87466
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87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning…
This requirement was not met as evidenced by:
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Licensee shall submit a Plan of Correction (POC) by 08/23/21 that details the steps to ensure the resident is provided with appropriate assistance.

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Based on interview, the Licensee did not ensure that R1 is regularly observed for changes and was not provided with appropriate assistance, which poses a potential health and safety risk 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: 08/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3