247206921-5-5-2023-24-AS-DAYS-CRJN39-20230505100556

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 247206921
Report Date: 05/04/2023
Date Signed: 05/05/2023 10:07:12 AM

Document Has Been Signed on 05/05/2023 10:07 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR:	DANIEL GORMLEY		FACILITY TYPE:	740
ADDRESS:	3420 R ST		TELEPHONE:	(209) 580-6124
CITY:	MERCED	STATE: CA	ZIP CODE:	95348
CAPACITY:	93	CENSUS: 67	DATE:	05/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Tracy Seibert - Memory Care Director		TIME COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 5/3/2023, Licensing Program Analyst(LPA) D. Ayers arrived unannounced to conduct a Required Annual Inspection. LPA met with Memory Care Director Tracy Seibert and announced the purpose of the visit. LPA toured the facility inside and outside. All passageways and exits were clear and free from obstruction. Fire extinguishers were recently serviced and facility has a sprinkler system. LPA toured the facility kitchen and observed an adequate supply of perishable and non-perishable foodstuffs. Kitchen and all common were well-lit, and odor-free. Facility had adequate supply of emergency food and first aid supplies. LPA reviewed emergency-disaster plan. LPA toured a sample of resident bedrooms and bathrooms. LPA toured facility memory care unit. LPA observed centrally stored medications in assisted living and memory care to be properly stored and secured, and medications appeared to be administered properly. LPA reviewed a sample of resident and staff files. Files contained required documentation and records. LPA requested the following files to be provided by 5/18/2023: LIC 500, LIC 308, LIC 9020a. During the inspection, LPA observed common areas and some resident bedrooms to have debris and dead bugs on the floor and along windows and window sills. LPA also observed food debris on the floor in the dining area. LPA observed one resident shower with a tiled floor to not have a non-skid mat. In the memory care kitchen area, LPA observed cleaning solution and Clorox spray stored in an unsecured cabinet below the sink. During records review, LPA observed that facility staff did not maintain adequate records of disaster/emergency drills. The last recorded fire drill was conducted 10/30/2019 at the time of inspection. See attached 809-D's for four type B citations issued in accordance with California Code of Regulations Title 22. A copy of the report and appeal rights were provided. Exit interview conducted.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David Ayers	TELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

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 05/05/2023 10:07 AM - 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
Lookup Error,
, CA

FACILITY NAME: PACIFICA SENIOR LIVING MERCED	FACILITY NUMBER: 247206921
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(5)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 6 resident bathrooms which were toured, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/18/2023
	Plan of Correction
1 2 3 4	Facility staff agreed to to ensure that all resident showers or bathtubs which do not have built-in non skid floors will be equipped with non-skid mats. Facility will provide proof to CCLD by POC due date.

Type B

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 6 kitchen cabinets in the memory care unit which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/04/2023
	Plan of Correction
1 2 3 4	Facility staff removed all cleaning solutions and disinfectants from unsecured areas while LPA was on-site.

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: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David Ayers	TELEPHONE: 559-408-4163
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/05/2023 10:07 AM - 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
Lookup Error,
, CA

FACILITY NAME: PACIFICA SENIOR LIVING MERCED	FACILITY NUMBER: 247206921
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in in 1 out of 1 emergency response binders, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/18/2023
	Plan of Correction
1 2 3 4	Facility agreed to provide proof of an emergency drill of facility choice conducted by facility staff to CCLD by POC due date. Facility staff will establish schedule of future ongoing emergency drills.

Type B

Section Cited

CCR

87303(a)

87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in multiple bedrooms and common areas, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/18/2023
	Plan of Correction
1 2 3 4	Facility agreed to provide proof of a general cleaning of floors, surface areas, and window sills to CCLD by POC due date.

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: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David Ayers	TELEPHONE: 559-408-4163
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC809 (FAS) - (06/04)

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