247206921-4-20-2022-24-AS-SPIY-CDPVHK-20220421162717

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 247206921
Report Date: 04/20/2022
Date Signed: 04/20/2022 01:38:52 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
01/25/2022 and conducted by Evaluator Lady Cabrera

COMPLAINT CONTROL NUMBER: 24-AS-20220125094342

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:	01:35 PM
MET WITH:	Shelly Randel, Executive Director		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Facility is not following COVID-19 protocol.

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: Facility is not following COVID-19 protocol.

Based on the interviews conducted and records review the above allegations are UNSUBSTANTIATED. On 02/02/2022 and on today’s date, LPA observed COVID precautionary measures were taken at the point of entry. 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.

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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