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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 247206921
Report Date: 10/01/2021
Date Signed: 10/01/2021 02:07:29 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
08/03/2021 and conducted by Evaluator Lady Cabrera
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20210803085608
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: 83DATE:
10/01/2021
UNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Tracy Seibert, Director (Designated Representative)TIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility staff did not effectively communicate with resident's responsible party.
Facility staff did not ensure that resident's room is clean.
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. Administrator Tyler Wilds is unavailable. Administrator designated Tracy Seibert to sign this report.

During this complaint investigation, it was discovered Licensee did not communicate with the Resident’s (R1) Responsible party/Representative listed on the Residence and Care Agreement. It was determined based on the interviews and records review that the above allegation is SUBSTANTIATED. On 02/09/2021, R1 received the 1st Dose Covid-19 vaccine without notifying R1’s Responsible Party/Representative.

Based on staff interview, staff confirmed not vacuuming R1’s room and received a verbal warning. Staff reported the facility resume using a housekeeper check list to indicate when a room has been cleaned. It was determined based on the interviews that the above allegation is SUBSTANTIATED. Facility staff did not ensure R1’s room is clean.

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: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021
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 6
Control Number 24-AS-20210803085608
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: 10/01/2021
NARRATIVE
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Based on LPA observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Deficiencies are being cited on the attached LIC 9099D.

Exit interview was conducted. A copy of this report, LIC9099, LIC9099D and appeal rights were provided. The Licensee’s signature on this form acknowledges receipt of these documents.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 24-AS-20210803085608
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: 10/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/15/2021
Section Cited
CCR
87468.1(a)(8)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (8)To have their representatives regularly informed by the licensee of activities related to care or services...
This requirement was not met as evidenced by:
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Licensee shall submit a Plan of Correction (POC) by 10/15/2021, Licensee to review 87468.1 Personal Rights of Residents. Licensee shall submit a written letter indicating they have read and understand the regulations to CCLD. LPA provided a copy of the regulation and PIN 21-14-ASC.
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Based on records review and interviews, the Licensee did not communicate with the R1's Responsible party/Representative listed on the Residence and Care Agreement, which poses a potential Health, Safety and Personal Rights risks to persons in care.

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Licensee to review all assisted living residents’ records to determine and maintain separately, which resident has a responsible party and which resident do not. Documents of this will be provided to CCL by 10/15/2021.
Type B
10/15/2021
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times…

This requirement was not met as evidenced by:
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Licensee shall submit a Plan of Correction (POC) by 10/15/2021, Licensee shall submit a written plan on how to ensure all residents rooms are maintain clean.


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Based on interviews, the Licensee did not ensure R1’s room is clean, which poses a potential Health, Safety and Personal
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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: 10/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
08/03/2021 and conducted by Evaluator Lady Cabrera
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20210803085608

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: 83DATE:
10/01/2021
UNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Tracy Seibert, Director (Designated Representative)TIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility staff did not follow resident's physician orders.
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 allegation. Administrator Tyler Wilds is unavailable. Administrator designated Tracy Seibert to sign this report.

During this complaint investigation, LPA reviewed facility records relevant to the complaint investigation. It was determined that the above allegation: Facility staff did not follow resident's physician orders is UNFOUNDED. Per records reviewed, interviews and physician’s written response, facility staff followed resident’s physician orders when tapering R1 off medications.

Exit interview was conducted. A copy of this report, LIC9099. The Licensee’s signature on this form acknowledges receipt of these documents.
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: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021
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 6
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
08/03/2021 and conducted by Evaluator Lady Cabrera
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20210803085608

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: 83DATE:
10/01/2021
UNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Tracy Seibert, Director (Designated Representative)TIME COMPLETED:
02:15 PM
ALLEGATION(S):
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2
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9
Facility has pests.
Facility staff did not ensure that resident takes medications.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Lady Cabrera conducted the complaint investigation visit to the facility. During this visit LPA delivered investigation findings regarding the above allegations. Administrator Tyler Wilds is unavailable. Administrator designated Tracy Seibert to sign this report.

The Department has investigated the complaint alleging: Facility has pests and Facility staff did not ensure that resident takes medications.

LPA reviewed pictures of cockroaches in Resident’s (R1) room. On 07/14/2021 and on 08/05/2021, EcoLab serviced the R1’s room and indicated no findings noted during service.

Per R1’s interview, R1 reported taking all the medications that the facility staff gives her. Per records review, R1 has refused taking medications.

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: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 24-AS-20210803085608
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: 10/01/2021
NARRATIVE
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Based on the interviews conducted and records review the above allegations are UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview was conducted. A copy of this report, LIC9099 and appeal rights were provided. The Licensee’s signature on this form acknowledges receipt of these documents.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6