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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 247206921
Report Date: 04/20/2022
Date Signed: 04/20/2022 12:50:19 PM

Unfounded


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
12/14/2021 and conducted by Evaluator Lady Cabrera
COMPLAINT CONTROL NUMBER: 24-AS-20211214083606
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: 79DATE:
04/20/2022
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH: Shelly Randel, Executive DirectorTIME COMPLETED:
12:49 PM
ALLEGATION(S):
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Resident fell while in care resulting in injury.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) L. Cabrera conducted the subsequent complaint 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.

The Department conducted interviews with staff and records reviewed. Per Resident’s (R1) initial assessment dated 05/22/2019, R1 is independent with transfers and ambulated independently with or without an assistive device. On 12/05/2021, R1 sustained an unwitnessed fall while using her scooter in her room. On 12/06/2021, R1 was discharged with Home Health and physical therapy. R1 was reassessed by the facility. The facility implemented a Care Plan, which indicates the interventions staff would use in order to minimize R1’s fall risk. Incident related to the fall is address in substantiated finding report.

This agency has investigated the complaint alleging (Lack of supervision resulting in resident's fall). We have found that the complaint was unfounded, therefore we have dismissed the complaint.
Exit interview was conducted. Administrator was provided with a copy of this report.
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: 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
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
12/14/2021 and conducted by Evaluator Lady Cabrera
COMPLAINT CONTROL NUMBER: 24-AS-20211214083606

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: DATE:
04/20/2022
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Shelly Randel, Executive Director TIME COMPLETED:
12:49 PM
ALLEGATION(S):
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Resident's care needs are not being met.
Resident's laundry needs are not being met.
Food service is inadequate.
Facility has pests.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) L. Cabrera conducted the subsequent complaint 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.

During this visit LPA delivered investigation findings regarding the above allegations. The Department has investigated the complaint alleging: Resident's care needs are not being met, Resident's laundry needs are not being met, Food service is inadequate, and Facility has pests.

R1 reported care needs were not being met such as the laundry, housekeeping service and the meal trays were cold when delivered to R1’s room. Per Admission Agreement signed and dated 06/03/2019 and interviews, Resident (R1) lived in Assisted Living. Facility provided laundry and housekeeping service on a weekly basis.

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: 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.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 24-AS-20211214083606
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: 04/20/2022
NARRATIVE
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Facility has the menu posted for residents and have an Always Available Menu for all residents. LPA interviewed residents and staff, it was reported that meal trays are cold or lukewarm when delivered. Per interviews, some staff will microwave the meal trays for the residents once the tray is delivered.

On 11/11/2021, EcoLab serviced R1’s room and indicated no findings noted during service. On 12/21/2021 and on 12/28/2021, LPA interviewed R1 in R1’s room. During the two visits, LPA did not observe any pests in R1’s room. Based on records and interviews, facility does have monthly pest control service but does have the occasional pests in facility.

Based on the interviews conducted and records review the above allegations are UNSUBSTANTIATED. 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 allegations are unsubstantiated.
Exit interview was conducted. Administrator was provided with a copy of this report.
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
LIC9099 (FAS) - (06/04)
Page: 6 of 7
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
12/14/2021 and conducted by Evaluator Lady Cabrera
COMPLAINT CONTROL NUMBER: 24-AS-20211214083606

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: DATE:
04/20/2022
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Shelly Randel, Executive DirectorTIME COMPLETED:
12:49 PM
ALLEGATION(S):
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Resident was left on floor for an extended period of time.
Staff are not responding to resident's call button in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) L. Cabrera conducted the subsequent complaint 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.

During the course of this complaint investigation LPA interviewed staff and obtained and reviewed facility records. It was determined based on the interviews and records review that the above allegations are SUBSTANTIATED.

On 12/05/2021, Resident (R1) had an unwitnessed fall. R1 pushed the call button 15 times and Staff (S2) responded within 21 minutes. Per call button records 10/01/2021-12/21/2021, staff will not respond to residents calls in a timely manner. Per interviews, it was reported the facility is short staff and will sometimes take longer to respond to the call buttons due to assisting other residents.

Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 24-AS-20211214083606
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: 04/20/2022
NARRATIVE
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Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 & Chapter 8, are being cited on the attached LIC 9099D.
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
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 24-AS-20211214083606
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/21/2022
Section Cited
CCR
87411(d)(3)
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87411Personnel Requirements -General (d) All personnel shall be given on the job training... shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (3) Skill and knowledge required to provide necessary resident care and supervision...
This requirement was not met as evidenced by:
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Licensee shall submit a plan of correction (POC) by 04/21/2022, that details the steps that will be taken to ensure that resident calls for assistance are responded to in a timely manner.
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Based on records reviewed and interviews, the Resident (R1) had an unwitnessed fall. R1 was left on the floor for an extended period of time and staff did not respond in a timely manner, which poses an Immediate health and safety risk to residents 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: 04/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 7