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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247206921
Report Date: 06/09/2021
Date Signed: 06/09/2021 04:27:59 PM

Document Has Been Signed on 06/09/2021 04:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:PACIFICA SENIOR LIVING MERCEDFACILITY NUMBER:
247206921
ADMINISTRATOR:TYLER WILDSFACILITY TYPE:
740
ADDRESS:3420 R STTELEPHONE:
(209) 580-6124
CITY:MERCEDSTATE: CAZIP CODE:
95348
CAPACITY: 93CENSUS: 70DATE:
06/09/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:07 PM
MET WITH:Tyler Wilds, AdministratorTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lady Cabrera conducted a subsequent Case Management (CM) visit to discuss information obtained from CM visit conducted on 05/26/2021.

The purpose of the visit is to address the incident that occurred on 03/23/2021 and 05/16/2021 Unusual incident report was submitted to CCLD by the facility staff. The incident that occurred on 03/23/2021 and on 05/16/2021 resulted in resident R1 going absent without leave (AWOL). Per Physician’s report dated 10/23/2019 R1 is unable to leave unassisted.



This is a second violation within the last twelve (12) months. Civil Penalty in the amount of $500 is assessed.

Exit interview conducted with Administrator and was provided with the LIC809, LIC809-D, LIC421IM and Appeal Rights.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2021
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 06/09/2021 04:27 PM - It Cannot Be Edited


Created By: Lady Cabrera On 06/09/2021 at 02:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: PACIFICA SENIOR LIVING MERCED
FACILITY NUMBER: 247206921

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/10/2021
Section Cited
HSC
1569.312

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§1569.312 Basic services requirements

Every facility required to be licensed under this chapter shall provide at least the following basic services:
(a) Care and supervision as defined in Section 1569.2.
*This requirement was not met as evidenced by:

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Licensee stated R1 was admitted to memory care unit. The plan of correction (POC) shall be a written statement from the licensee describing how licensee will comply with this section of the regulation.
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The incident occurred on 03/23/2021 and 5/16/2021 which resulted in resident R1 going AWOL from the facility. R1 is/was unable to leave the facility unassisted per Physician Report dated 10/23/2019. This presents an immediate risk to the health, safety or personal rights of the clients 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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Lady Cabrera
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2021


LIC809 (FAS) - (06/04)
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