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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247206921
Report Date: 02/02/2022
Date Signed: 02/02/2022 02:38:45 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: 84DATE:
02/02/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Shelly Randel, Business Manager and Daniel Gormley, Acting AdministratorTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lady Cabrera conducted an unannounced Case Management visit. The purpose of the visit is to follow up on the administration of the facility. LPA met with Shelly Randel, Business Manager and Daniel Gormley, Acting Administrator.

On 12/21/2021, LPA met with Tracey Seibert, Memory Care Director (MCD) and Acting Administrator Daniel Gormley. LPA was informed that Administrator Tyler Wilds was transferred to another state two weeks prior. On 12/22/2021, LPA emailed Acting Administrator and MCD the change of administrator requirements and the 87211 Reporting Requirements regulations.

As of today’s, date the Department has not received notice as to the status whether a new administrator has been hired.

LPA reviewed the Unusual incident report that occurred on 01/12/2021, which resulted of Resident (R1) going absent without leave (AWOL) at approximately 3a.m. R1 was last seen approximately at 1a.m. Facility immediately contacted Merced PD. Resident was located across the street inside the The Hampshire Independent Living by Merced PD approximately at 5:30a.m. R1 was reassessed and admitted to Memory Care. Per Physician's Report dated 1/21/2020, R1 is unable to leave the facility unassisted.



Deficiencies cited on LIC809D.

Exit interview conducted and Designated Representative 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: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
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: 02/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/03/2022
Section Cited

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§1569.312 Basic services requirements

Every facility required to be licensed under this chapter shall provide at least the following basic services:
(a) Care and supervision as defined in Section 1569.2.
*This requirement was not met as evidenced by:

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The incident occurred on 01/12/2021 which resulted in resident R1 going AWOL from the facility. R1 is/was unable to leave the facility unassisted per Physician Report dated 1/21/2020. This presents an immediate risk to the health, safety or personal rights of the clients in care.
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Type B
02/15/2022
Section Cited

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87211 Reporting Requirements (g) The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator… This requirement was not met as evidenced by:
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Based on interviews and records review, the Licensee has not notified the Department, in writing of a new facility administrator, 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: 02/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2022
LIC809 (FAS) - (06/04)
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