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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247206921
Report Date: 02/08/2022
Date Signed: 02/08/2022 09:41:51 AM

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:
02/08/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Daniel Gormley, Operations Specialist and Shelly Randel, Business Office TIME COMPLETED:
09:45 AM
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An Informal Office Meeting was held on 02/08/2022 at the Fresno Regional Office.
The purpose of the meeting is to discuss recently identified issues/ concerns associated with the operation of the facility.
In attendance:

Shelly Randel, Business Office Director,
Daniel Gormley, Operations Specialist, Licensee Representative

Brenda White, Regional Manager
Sergiy Pidgirny, Licensing Program Manager
Lady Cabrera, Licensing Program Analyst

The following issues/ concerns associated with the operation of the facility were brought forward and discussed with the Licensee Representative:

1. Accountability of Licensee Governing Body
2. Administrator - Qualifications and Duties
3. Personnel Requirements - General
4. Personnel - Operations
5.Basic Services (Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).)
6.Incidental Medical and Dental Care
7. Personal Rights
8. Maintenance and Operation
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022
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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