247206921-4-21-2025-24-AS-KHOS-DG6PVF-20250428113904

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 247206921
Report Date: 04/17/2025
Date Signed: 04/21/2025 12:42:57 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
04/11/2025 and conducted by Evaluator Vadim Gorban

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20250411131032

FACILITY NAME:	PACIFICA SENIOR LIVING MERCED		FACILITY NUMBER:	247206921
ADMINISTRATOR:	EMILY VENEGAS		FACILITY TYPE:	740
ADDRESS:	3420 R ST		TELEPHONE:	(209) 580-6124
CITY:	MERCED	STATE: CA	ZIP CODE:	95348
CAPACITY:	93	CENSUS: 75	DATE:	04/17/2025
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	administrator Lisa Baricevic		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Staff do not follow infection control requirements

INVESTIGATION FINDINGS:

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On 04/17/2025, Licensing Program Analyst (LPA) V. Gorban conducted an unannounced complaint investigation visit on the above allegations. LPA explained the purpose of visit to Administrator Lisa Baricevic.

During the course of the investigation, LPA conducted a facility tour, reviewed records, and conducted interviews.
The Department has investigated the allegation: staff do not follow infection control requirements. Based on interviews and records reviewed, it was found that the facility is following infection control requirements. LPA discovered that R1 is able to empty and drain their own ostomy bag. Additionally, R2 is receiving care from a hospice agency. 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.

Exit interview conducted. Report signed on-site and a copy of this report was provided to the Administrator for facility records.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim Gorban	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

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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