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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247206921
Report Date: 03/04/2021
Date Signed: 03/22/2021 03:30:36 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
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: 66DATE:
03/04/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:05 PM
MET WITH:Tyler Wilds, AdministratorTIME COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lady Cabrera conducted an unannounced Case Management-Deficiencies visit via telephone due to COVID-19 and pre-cautionary measures. LPA informed Administrator the purpose of the inspection and deficiencies were discussed.

During the investigation, Community Care Licensing (CCLD) was provided with written statements of staff indicating their observations of Unusual Incident/Injury Reports that occurred on 1/21/2020, which were submitted on 1/27/2021 to CCLD.

Based on the LPAs interviews and records review, the Licensee did not meet California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87468.1(a)(3) Personal Rights of Residents. Based on the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited on the attached LIC 809-D.

Exit interview conducted with Administrator and was provided with the LIC809, LIC809-D, and Appeal Rights.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/04/2021
Section Cited

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87468.1(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3) To be free from punishment, humiliation, intimidation, abuse, or other actions...interfering with daily living functions such as eating, sleeping...

This requirement is not met as evidenced by:
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Based on observation, records review and interview, the Licensee did not meet the Personal Rights of the residents, which poses a Potential 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: 03/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2021
LIC809 (FAS) - (06/04)
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