247206921-9-29-2022-24-AS-LCAA-CJQUJR-20220929153757

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 247206921
Report Date: 09/29/2022
Date Signed: 09/29/2022 03:38:13 PM

Document Has Been Signed on 09/29/2022 03:38 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 MERCED		FACILITY NUMBER:	247206921
ADMINISTRATOR:	DANIEL GORMLEY		FACILITY TYPE:	740
ADDRESS:	3420 R ST		TELEPHONE:	(209) 580-6124
CITY:	MERCED	STATE: CA	ZIP CODE:	95348
CAPACITY:	93	CENSUS: 77	DATE:	09/29/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:48 PM
MET WITH:	Shelly Randel, Executive Director		TIME COMPLETED:	04:00 PM

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Licensing Program Analyst (LPA) L. Cabrera conducted an unannounced Case Management visit. LPA met with Shelly Randel, Executive Director. Administrator was unavailable and designated Shelly Randel to meet with LPA.

CCL Office received Unusual Incident/Injury Report (SIR) dated 07/06/2022. LPA follow-up regarding Resident (R1) not knowing how much Tylenol resident took. Facility immediately called the ambulance and R1 was transported to the Hospital. Facility is now administering all medications for R1. LPA requested new Physician’s Report for R1.

CCL Office received Unusual Incident/Injury Report (SIR) dated 07/24/2022. LPA follow-up regarding R2 stage of wound on right hand. Per records reviewed, R2 has a skin tear only.

CCL Office received Unusual Incident/Injury Report (SIR) dated 09/02/2022. LPA follow-up regarding R3 health and safety. No follow-up needed.

CCL Office received Unusual Incident/Injury Report (SIR) dated 09/04/2022. On 09/07/2022, ED reported the incident to CCL. LPA follow-up regarding R4 absent without leave (AWOL). It was reported that on 09/04/2022, R4 went AWOL from the facility. On 08/27/2022, the egress door was out of service. ED implemented a plan for staff to conduct 15 minutes checks and document it. According to ED, all residents were accounted for at 9:45a.m. Two staff were assisting another resident while third staff was at lunch. ED reported there was no supervision in the common area.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lady Cabrera	TELEPHONE: (559) 513-9832
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022

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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Document Has Been Signed on 09/29/2022 03:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/29/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/30/2022 Section Cited	1 2 3 4 5 6 7	HS§1569.312 Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. This requirement was not meant by:
	8 9 10 11 12 13 14	The incident occurred on 09/04/2022 resulted in Memory Care resident R4 going AWOL from the facility. There was no supervision in the common area, which poses an immediate risk to the health, safety or personal rights of the clients in care. Per R4’s Physician’s Report dated 03/07/2021, R4 has mild cognitive impairment and is unable to leave facility unassisted.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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 Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lady Cabrera	TELEPHONE: (559) 513-9832
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/29/2022

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During the 10a.m. count, R4 was not accounted for. Facility conducted a search for R4. At 10:30a.m., Merced Police Department (MPD) was notified and MPD confirmed they had R4. ED reported R4 is a resident in Memory Care. R4 was transported to Mercy Hospital and returned on the same date.

Per R4’s Physician’s Report dated 03/07/2021, R4 has mild cognitive impairment and is unable to leave facility unassisted. On 05/14/2021, R4 was admitted to Memory Care.

A civil penalty is being cited, per California Code of Regulations, Title 22, Division 6, see attached 421IM.

Exit interview conducted and Designated Representative was provided with the LIC809, LIC809-D and Appeal Rights.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lady Cabrera	TELEPHONE: (559) 513-9832
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022

LIC809 (FAS) - (06/04)

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