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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247206921
Report Date: 04/20/2022
Date Signed: 04/20/2022 01:57:37 PM


Document Has Been Signed on 04/20/2022 01:57 PM - It Cannot Be Edited

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:DANIEL GORMLEYFACILITY TYPE:
740
ADDRESS:3420 R STTELEPHONE:
(209) 580-6124
CITY:MERCEDSTATE: CAZIP CODE:
95348
CAPACITY:93CENSUS: 79DATE:
04/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:39 PM
MET WITH:Shelly Randel, Executive DirectorTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) L. Cabrera conducted a case management visit on this date. LPA met with Shelly Randel, Executive Director due to Administrator Daniel Gormley was unavailable. LPA spoke with Administrator and approved for LPA to meet with the Executive Director. LPA stated the purpose of the visit.

LPA received a death report for Resident (R1) and LPA requested R1 records to be submitted by 4/21/2022 to CCL.

No deficiencies cited. LPA will follow-up once the records and interviews have been conducted.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2022
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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