<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 247206921
Report Date: 03/02/2023
Date Signed: 03/02/2023 01:56:32 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
12/15/2022 and conducted by Evaluator Kamaldeep Kaur
COMPLAINT CONTROL NUMBER: 24-AS-20221215083348
FACILITY NAME:PACIFICA SENIOR LIVING MERCEDFACILITY NUMBER:
247206921
ADMINISTRATOR:DANIEL GORMLEYFACILITY TYPE:
740
ADDRESS:3420 R STTELEPHONE:
(209) 580-6124
CITY:MERCEDSTATE: CAZIP CODE:
95348
CAPACITY:93CENSUS: 70DATE:
03/02/2023
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Shelly Randel, Executive DirectorTIME COMPLETED:
01:54 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility has expired foods
Staff do not keep the facility free from insects
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) K. Kaur arrived at the facility unannounced for subsequent complaint inspection. LPA discussed the purpose of the visit and the elements of the allegations with administrator. LPA delivered the following findings.

Based on interviews conducted and observation the facility had expired foods in the facility refrigerator and freezer. The facility was also observed with insects in several of the resident’s rooms.

The preponderance of evidence standard has been met, therefore the above allegations are found to be
SUBSTANTIATED. See citations on the attached LIC9099D. Exit interview was conducted with Administrator and appeal rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
12/15/2022 and conducted by Evaluator Kamaldeep Kaur
COMPLAINT CONTROL NUMBER: 24-AS-20221215083348

FACILITY NAME:PACIFICA SENIOR LIVING MERCEDFACILITY NUMBER:
247206921
ADMINISTRATOR:DANIEL GORMLEYFACILITY TYPE:
740
ADDRESS:3420 R STTELEPHONE:
(209) 580-6124
CITY:MERCEDSTATE: CAZIP CODE:
95348
CAPACITY:93CENSUS: DATE:
03/02/2023
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Shelly Randel, Executive DirectorTIME COMPLETED:
01:54 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not ensure elevators are serviced as required

INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) K. Kaur conducted a subsequent complaint inspection to deliver findings. LPA met with Executive Director Shelly Randel, and explained the purpose of the visit and reviewed the elements of the allegation. LPA delivered the following complaint investigation findings.

The above listed allegation were investigated. Based on observation, interviews conducted and records reviewed the facility has a quarterly maintenance agreement with Elevator company. The Department found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted. Report signed on-site by Executive Director; a copy of this report was provided.

Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
12/15/2022 and conducted by Evaluator Kamaldeep Kaur
COMPLAINT CONTROL NUMBER: 24-AS-20221215083348

FACILITY NAME:PACIFICA SENIOR LIVING MERCEDFACILITY NUMBER:
247206921
ADMINISTRATOR:DANIEL GORMLEYFACILITY TYPE:
740
ADDRESS:3420 R STTELEPHONE:
(209) 580-6124
CITY:MERCEDSTATE: CAZIP CODE:
95348
CAPACITY:93CENSUS: DATE:
03/02/2023
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Shelly Randel, Executive DirectorTIME COMPLETED:
01:54 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained a fracture while in care
Insufficient staffing to provide adequate supervision of residents in care
Facility refrigerator is in disrepair
Resident funds were stolen by staff


INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) K. Kaur conducted a subsequent complaint inspection to deliver findings. LPA met with Executive Director Shelly Randel, and explained the purpose of the visit and reviewed the elements of the allegation. LPA delivered the following complaint investigation findings.

The Department investigated the allegation listed above. Based on the interviews conducted, the allegations regarding 1) resident sustained a fracture while in care and 2) Insufficient staffing to provide adequate supervision of residents in care are Unsubstantiated. Based on observation the Facility refrigerator appeared clean and in working order. Based on interviews conducted and records reviewed no incident was found that indicated Resident funds were stolen by staff.

Based on observation and interview of staff and residents, the above allegations are UNSUBSTANTIATED.
Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove
that the alleged violations did or did not occur, therefore these allegations are unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023
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 4
Control Number 24-AS-20221215083348
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PACIFICA SENIOR LIVING MERCED
FACILITY NUMBER: 247206921
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/02/2023
Section Cited
CCR
87555(b)(8)
1
2
3
4
5
6
7
87555 (b) (8) General Food Service Requirements. The following food service requirements shall apply: All food shall be of good quality.

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
***POC has been completed during the subsequent visit*** Administrator discussed with food and nutrition director the need to make sure all food is checked on a daily bases to remove any food that is going moldy or expired.
8
9
10
11
12
13
14
Based on observation Licensee did not keep foods of good quality when refrigerator observed to store fruit that was moldy.
8
9
10
11
12
13
14
Type B
03/17/2023
Section Cited
CCR
80087(a)(1)
1
2
3
4
5
6
7
80087 Buildings and Grounds (a)The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1)The licensee shall take measures to keep the facility free of flies and other insects.

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Plan of Correction POC Licensee agrees to
have pest control service the facility and
Licensee will submit reciept by POC due date
8
9
10
11
12
13
14
Based on observation Licensee did not keep facility free of insects, ants observed in resident rooms 103, 105 and 208 which poses a potential health, safety personal rights risk to clients in care.
8
9
10
11
12
13
14
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: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4