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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 247206921
Report Date: 12/10/2025
Date Signed: 12/10/2025 06:58:12 PM

Unsubstantiated


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
09/12/2025 and conducted by Evaluator Vadim Gorban
COMPLAINT CONTROL NUMBER: 24-AS-20250912133337
FACILITY NAME:MERCED SENIOR LIVINGFACILITY NUMBER:
247206921
ADMINISTRATOR:LISA BARICEVICFACILITY TYPE:
740
ADDRESS:3420 R STTELEPHONE:
(209) 580-6124
CITY:MERCEDSTATE: CAZIP CODE:
95348
CAPACITY:93CENSUS: 84DATE:
12/10/2025
UNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Wellness Director Tracy Gaddess TIME COMPLETED:
11:48 AM
ALLEGATION(S):
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Staff did not provide activities for resident
Staff did not seek medical attention for resident’s change in condition
Staff did not notify authorized representative of resident's change in condition
Staff did not ensure medications were dispensed as prescribed
INVESTIGATION FINDINGS:
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On 12/26/2025, Licensing Program Analyst (LPA) V Gorban conducted subsequent complaint inspection. LPA met with Wellness Director (WD). The purpose of this visit is to deliver the findings of the investigation completed by the Department.
During the visit, LPA conducted a tour of the facility, interior and exterior to ensure there is no potential or immediate health and safety risk at the facility.
LIC 9099D
Allegation: Staff did not provide activities for resident. Based on interviews and records staff follow daily activities according to facility planner posted on the facility wall. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Report continues on attached LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2025
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
09/12/2025 and conducted by Evaluator Vadim Gorban
COMPLAINT CONTROL NUMBER: 24-AS-20250912133337

FACILITY NAME:MERCED SENIOR LIVINGFACILITY NUMBER:
247206921
ADMINISTRATOR:LISA BARICEVICFACILITY TYPE:
740
ADDRESS:3420 R STTELEPHONE:
(209) 580-6124
CITY:MERCEDSTATE: CAZIP CODE:
95348
CAPACITY:93CENSUS: 84DATE:
12/10/2025
UNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Wellness Diretor Tracy GaddessTIME COMPLETED:
11:48 AM
ALLEGATION(S):
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Resident sustained an unexplained injury
INVESTIGATION FINDINGS:
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On 12/26/2025, Licensing Program Analyst (LPA) V Gorban conducted subsequent complaint inspection. LPA met with WD. The purpose of this visit is to deliver the findings of the investigation completed by the Department.

During the visit, LPA conducted a tour of the facility, interior and exterior to ensure there is no potential or immediate health and safety risk at the facility.

Allegation: Resident sustained an unexplained injury. Based on records review, R1 was observed in the community with facial injury, unknown to staff. On May 8th R1 was taken to medical evaluation out of the community by family. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations being cited on the attached LIC 9099D
Exit interview conducted, report signed and with appeal rights provided to WD for facility records.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2025
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
Control Number 24-AS-20250912133337
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: MERCED SENIOR LIVING
FACILITY NUMBER: 247206921
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/15/2025
Section Cited
CCR
87411(a)
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87411 Personnel Requirements. (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary...... This requirement was not observed as evidenced by:
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The facility administrator or staff will provide a written statement describing on following regulation by POC due date to LPA by email.
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Based on records review facility failed following Title 22 regulation regarding supervision resulting in one out of eighty four residents acquired facial injury and staff was not aware of the incident. This is poses potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 24-AS-20250912133337
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: MERCED SENIOR LIVING
FACILITY NUMBER: 247206921
VISIT DATE: 12/10/2025
NARRATIVE
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Allegation: Staff did not seek medical attention for resident’s change in condition. Based on records reviews, R1 was sent out on multiple occasions including May 8th, May 17th, May 19th, and May 30th due to aggression and medication adjustments. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Staff did not notify authorized representative of resident's change in condition. Based on records reviews, on May 19th family responsible party was notified of the incident via phone call, on May 21st, and May 30th family member either visited R1 or was notified by the facility of R1 behavior. In addition, responsible party signed updated changes of condition increased level of care from level one to level 2 on 5/21/25. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Staff did not ensure medications were dispensed as prescribed. Based on records review and interviews, medication A and B were administered as prescribed. R1 medication records indicated on May 7th, 20th, 21st, 26th, and 27th, R1 either refused medications or R1 was out of the community with family, per records medications were dispensed as prescribed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Report continues on attached LIC9099-A

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4