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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247206921
Report Date: 04/23/2024
Date Signed: 04/26/2024 09:53:17 AM


Document Has Been Signed on 04/26/2024 09:53 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 MERCEDFACILITY NUMBER:
247206921
ADMINISTRATOR:DANIEL GORMLEYFACILITY TYPE:
740
ADDRESS:3420 R STTELEPHONE:
(209) 580-6124
CITY:MERCEDSTATE: CAZIP CODE:
95348
CAPACITY:93CENSUS: 70DATE:
04/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Emily Venegas - AdministratorTIME COMPLETED:
12:30 PM
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On 4/23/2024, Licensing Program Analyst(LPA) D. Ayers arrived unannounced to conduct a Required Annual Inspection. LPA met with Executive Director Emily Venegas 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 had a sprinkler system. LPA reviewed facility emergency disaster plan and record of emergency drills. LPA toured the facility kitchen and observed an adequate supply of perishable and non-perishable foodstuffs. Kitchen and all common areas were clean, well-lit, and odor-free. Facility had adequate supply of emergency food and first aid supplies.

LPA toured a sample of resident bedrooms and bathrooms. Bedrooms and bathrooms were clean and odor-free. Bedrooms had required minimum furnishings and were at a comfortable temperature. Bathrooms had secure grab bars and non-slip floors. LPA toured facility memory care unit and observed some residents participating in planned activities. LPA reviewed a sample of resident and staff files. Files contained required documentation and records. LPA requested the following files to be provided by 4/30/2024: LIC 500, LIC 308, LIC 9020a.

At 10:15 am, LPA observed that a centrally stored medication was expired, but was still stored in the medication cart with the resident's other medications. During tour of the facility, it was observed that at least three storage bins in resident bathrooms and one in a common bathroom were not fitted with tight-fitting covers. See attached LIC 809D for two type-B deficiencies cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8.

A copy of the report and appeal rights were provided to the administrator via email. Exit interview conducted.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David AyersTELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024
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 04/26/2024 09:53 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
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: 04/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(i)
87465 Incidental Medical and Dental Care (i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy…shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above for at least 1 out of 70 residents, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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Administrator agreed to provide a record of destruction of expired medications by POC due date.
Type B
Section Cited
CCR
87303(f)(3)
87303 Maintenance and Operation (f) Solid waste shall be stored and disposed of as follows: (3) All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers; shall be in good repair; shall have external handles; and shall be leakproof and rodent-proof.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in the bathrooms of ate least 3 out of 70 residents' bathrooms, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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Administrator agreed to replace any containers used for storage of solid wastes to be replaced or altered to have tight-fitting covers 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 ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David AyersTELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024
LIC809 (FAS) - (06/04)
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