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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 247206921
Report Date: 12/28/2021
Date Signed: 12/28/2021 01:37:04 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
11/23/2021 and conducted by Evaluator Lady Cabrera
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20211123122945
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: 80DATE:
12/28/2021
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Tracy Seibert, Memory Care DirectorTIME COMPLETED:
01:35 PM
ALLEGATION(S):
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Residents sustaining pressure injuries while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPAs) Kamaldeep Kaur and Lady Cabrera conducted an unannounced subsequent complaint visit on this date. LPAs met with Tracy Seibert, Memory Care Director the Acting Administrator Daniel Gormley was unavailable. LPAs and stated the purpose of the visit.

During the course of this investigation LPA reviewed facility files relevant to the complaint investigation. It was determined that the above allegation: Residents sustaining pressure injuries while in care is UNFOUNDED. The facility confirmed having Resident (R2) being diagnosed with pressure injuries. Per R2’s Primary Physician, R2 has two wounds that are stage 2. R2 is being seen by Compassionate Home health and her primary physician. If R2’s conditions do not improve, then she will be referred to wound care clinic for further evaluation. Per California Code of Regulations, Title 22, Division 6, Chapter 8, Article 11, Section 87631(a)(3), the facility is able to retain a resident who has healing wound…with stage two pressure injury…the resident shall receive care for the pressure injury from a physician or an appropriately skilled facility.
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: 12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021
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-20211123122945
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: 12/28/2021
NARRATIVE
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This agency has investigated the complaint alleging (Residents sustaining pressure injuries while in care). We have found that the complaint was unfounded, therefore we have dismissed the complaint.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
11/23/2021 and conducted by Evaluator Lady Cabrera
COMPLAINT CONTROL NUMBER: 24-AS-20211123122945

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: 80DATE:
12/28/2021
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Tracy Seibert, Memory Care DirectorTIME COMPLETED:
01:35 PM
ALLEGATION(S):
1
2
3
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9
Staff do not keep the facility free from odor
INVESTIGATION FINDINGS:
1
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3
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5
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7
8
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12
13
Licensing Program Analyst (LPAs) Kamaldeep Kaur and Lady Cabrera conducted an unannounced subsequent complaint visit on this date. LPAs met with Tracy Seibert, Memory Care Director the Acting Administrator Daniel Gormley was unavailable. LPAs and stated the purpose of the visit.

The Department has investigated the complaint alleging: Staff do not keep the facility free from odor. Based on the interviews conducted the above allegation is UNSUBSTANTIATED. On 11/24/2021, LPA observed an odor of urine on the east side of the Memory Care building, however, at the time of the facility visit staff were washing soiled linens and the laundry room door was open. Per facility staff interviews, staff will clean and disinfect the facility every shift. 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 allegation is unsubstantiated.

Exit interview conducted. LPA provided a copy of this report 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: 12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3