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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 247206921
Report Date: 03/12/2025
Date Signed: 03/13/2025 08:28:01 AM

Substantiated


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
03/10/2025 and conducted by Evaluator Vadim Gorban
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20250310162656
FACILITY NAME:PACIFICA SENIOR LIVING MERCEDFACILITY NUMBER:
247206921
ADMINISTRATOR:EMILY VENEGASFACILITY TYPE:
740
ADDRESS:3420 R STTELEPHONE:
(209) 580-6124
CITY:MERCEDSTATE: CAZIP CODE:
95348
CAPACITY:93CENSUS: 84DATE:
03/12/2025
UNANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:administrator Lisa BaricevicTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility staff did not provide resident reappraisal upon change in condition
INVESTIGATION FINDINGS:
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On 03/12/2025, Licensing Program Analyst (LPA) V Gorban unannounced visited facility stated above to commence a complaint investigation, stated the purpose of the visit and was allowed entry into the facility by Administrator (AD) Lisa .

Allegation: Facility staff did not provide resident reappraisal upon change in condition. During this visit LPA toured the facility performing safety checks, also LPA interviewed Administrator, facility staff and resident. Based on interviews and observation R1 did not receive updated documents of re -appraisal due change the level of care, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, are being cited on the attached LIC 9099D


Exit interview conducted and copy of this report provided to Administrator for facility records.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 24-AS-20250310162656
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: PACIFICA SENIOR LIVING MERCED
FACILITY NUMBER: 247206921
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/14/2025
Section Cited
CCR
87507(e)
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87507 Admission Agreements. (e) The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative... This requirement was not observed as evidenced by:
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The facility administrator will provide education and traning to personnel and provide an official statement were facility will provide a responsible party with any updates made to residents' records to LPA by email following POC due date.
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facility staff failed to provide the resident with updated re-appraisal for resident knowledge and records. 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.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC9099 (FAS) - (06/04)
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