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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 247206921
Report Date: 03/20/2024
Date Signed: 03/28/2024 02:14:35 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 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
01/16/2024 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 24-AS-20240116092943
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: 68DATE:
03/20/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Emily VenegasTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Due to lack of staff, calls for assisance are not answered timely
Due to staff neglect, resident missed medications
Staff are not following residents care plan
Due to neglect, resident has fallen multiple times
Authorized representative has not received a copy of the care plan
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings a complaint on the allegations listed above. LPA met with facility Administrator Emily Venegas and explained the purpose of today's visit.

Regarding the allegation Due to lack of staff, calls for assistance are not answered timely. LPA Hurt reviewed records titled “Resident Event Report” documenting response times when Resident 1 pushed his pendant alarm. On 01/09/2024 the response time for staff to assist Resident 1 was 80 minutes, on 01/10/2024 the response time for staff to assist Resident 1 was 61 minutes, on 01/11/1024 the staff response time to assist Resident 1 was 55 minutes. Resident 1 stated when pushing his pendant alarm requesting staff assistance, he was having to wait at times more than hour before facility staff assisted. Based on LPAs interviews, and records reviewed which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED

Continued..





Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024
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 5
Control Number 24-AS-20240116092943
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: PACIFICA SENIOR LIVING MERCED
FACILITY NUMBER: 247206921
VISIT DATE: 03/20/2024
NARRATIVE
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Continued..

Regarding the allegation Due to staff neglect, resident missed medications. LPA Hurt reviewed Centrally Stored Medication Logs, and Medication Administration Record for facility Resident 1. The Centrally Stored log lists several medications to be given daily to Resident 1. The MAR documents Resident 1 was not given most medications from 01/08/2024 to 01/18/2024. Based on records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED

Regarding the allegation Staff are not following residents care plan. LPA Hurt reviewed facility records titled “Needs and Services Plan” for facility Resident 1. The Needs and Services Plan documents Resident 1 needs transfer assistance. Resident 1 was waiting over an hour after pushing his pendant for staff to assist with transfer. Based on records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED

Regarding the allegation Due to neglect, resident has fallen multiple times. Resident 1 was not assisted timely by facility staff when attempting to transfer resulting in multiple falls. Facility staff did state they attempt to assist all residents when they call for assistance, but they are short staffed and residents are unfortunately having long wait times while they assist other residents. Based on interviews conducted, and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED


Regarding the allegation Authorized representative has not received a copy of the care plan. LPA Hurt reviewed records titled “Resident assessment” for facility Resident 1. This document was not signed by Resident 1 or their Responsible party. LPA Hurt interviewed Resident 1’s Responsible Party who stated they requested and were never provided a copy of the “Resident Assessment.” Based on LPA interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED

Exit interview conducted with Administrator Emily Venegas, and a copy of this report provided.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 24-AS-20240116092943
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PACIFICA SENIOR LIVING MERCED
FACILITY NUMBER: 247206921
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/21/2024
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General(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 to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. The following requirement has ot been met as evidenced by:
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Administrator will ensure sufficient staff is provided to care for facility residents, and provide proof to LPA by POC date of 03/21/2024.
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Resident 1's wait time for assistance when pushing his pendant was at times more than 60 minutes, which poses an immediate health, safety, or personal rights risk to residents in care.
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Type A
03/21/2024
Section Cited
CCR
87465(a)
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87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. The following requirement has not been met as evidenced by:
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Administrator will train facility medication technicians on facility resident admission process and submit proof to LPA by POC date of 03/21/2024.
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Resident 1 was not provided medications listed on medication list, which poses an immediate health, safety, or personal rights risk to residents 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.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 24-AS-20240116092943
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PACIFICA SENIOR LIVING MERCED
FACILITY NUMBER: 247206921
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/03/2024
Section Cited
CCR
87464(d)
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87464 Basic Services (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources. The following requirement has not been met evidenced by:
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Administrator will conduct training with all facility staff on providing Basic Services for facility residents and provide proof to LPA by POC date of 04/03/2024.
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 Resident 1 was not correctly assisted with medications or transfers as listed on pre admission, which poses a potential, health, safety or personal rights risk to residents in care.
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Type B
04/03/2024
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
The following requirement has not been met as evidenced by:
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Administrator will conduct staff training on assisting residents timely and submit proof to LPA by POC date of 04/03/2024.
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Resident 1 was not assisted by staff with transfers resulting in several falls, which poses a potential , health, safety, or personal rights risk to residents 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.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 24-AS-20240116092943
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PACIFICA SENIOR LIVING MERCED
FACILITY NUMBER: 247206921
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/03/2024
Section Cited
CCR
87457(a)(3)
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87457 Pre-Admission Appraisal - General (a) Prior to admission, the prospective resident and his/her responsible person, if any, shall be interviewed by the licensee or the employee responsible for facility admissions(3) The prospective resident, or his/her responsible person, if any, shall be involved in the development of the appraisal.
The following requirement has not been met as evidenced by:
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Adminsitrator will provide training to facility staff on Admission process, and send proof to LPA Hurt by POC date of 04/03/2024.
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Resident 1's Responsible Party was not provided and did not sign Resident Assesment or Needs and Services plan, which poses a potential, health, safety, or personal rights risk to residents 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.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5