247206921-4-20-2022-24-AS-SPIY-CDPVLH-20220421163158

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 247206921
Report Date: 04/20/2022
Date Signed: 04/20/2022 01:28:38 PM

Unsubstantiated

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
01/07/2022 and conducted by Evaluator Lady Cabrera

COMPLAINT CONTROL NUMBER: 24-AS-20220107164106

FACILITY NAME:	PACIFICA SENIOR LIVING MERCED		FACILITY NUMBER:	247206921
ADMINISTRATOR:	TYLER WILDS		FACILITY TYPE:	740
ADDRESS:	3420 R ST		TELEPHONE:	(209) 580-6124
CITY:	MERCED	STATE: CA	ZIP CODE:	95348
CAPACITY:	93	CENSUS: 79	DATE:	04/20/2022
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Shelly Randel, Executive Director		TIME COMPLETED:	01:28 PM

ALLEGATION(S):

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Staff behaviors poses as a risk to the residents while in care
Residents are sustaining falls while in care
Residents are left soiled for extended periods of time
Staff are stealing the residents medications

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: Staff behaviors poses as a risk to the residents while in care, Residents are sustaining falls while in care, Residents are left soiled for extended periods of time and Staff are stealing the residents medications.

On 1/23/2022, LPAs interviewed facility Business Manager and Memory Care Director, it was reported no internal investigations or incidents involving staff. It was reported to the complainant that residents are sustaining falls and residents are left soiled for extended periods of time due to staff behaviors. LPA reviewed all reported fall related incident reports and interviewed Bristol Hospice staff. Per records and interviews, there are no concerns at this time regarding residents being left soiled for extended periods of time.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady Cabrera	TELEPHONE: (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)

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Control Number 24-AS-20220107164106

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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On 01/13/2022, LPAs conducted a medication count and reviewed Centrally Stored Medication with facility staff. LPAs did not observe any errors with residents’ medications count. LPA reviewed resident’s Medication Administration Record (MAR) and it appears medication was given as prescribed.

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 Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady Cabrera	TELEPHONE: (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)

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