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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 01:14:10 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
12/29/2021 and conducted by Evaluator Lady Cabrera
COMPLAINT CONTROL NUMBER: 24-AS-20211229162747
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:
12:54 PM
MET WITH:Shelly Randel, Executive DirectorTIME COMPLETED:
01:11 PM
ALLEGATION(S):
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Bedridden residents are not being turned every two hours.
Residents are not receiving timely assistance with incontinence needs.
Facility has roaches.
Facility is not offering activities.
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: Bedridden residents are not being turned every two hours, Residents are not receiving timely assistance with incontinence needs and Facility has roaches.

Per records reviewed and Bristol Hospice-California interviews, there are no concerns at this time regarding the residents not being repositioned and not receiving timely assistance with incontinence needs. Per Bristol Hospice, some residents are self-alert and not alert to their surroundings. Per records and interviews, facility will post a monthly calendar for residents to participate. Staff will conduct sensory activities and one on one activies in the residents room.
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: 1 of 2
Control Number 24-AS-20211229162747
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 today’s date, LPA was provided with a sign out sheet for a residents' outing as part of a facility activity. 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: 2 of 2