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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247206921
Report Date: 05/03/2023
Date Signed: 05/03/2023 02:32:24 PM


Document Has Been Signed on 05/03/2023 02:32 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710



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: 65DATE:
05/03/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:54 PM
MET WITH:Shelly Randel, Executive Director (Administrator)TIME COMPLETED:
02:45 PM
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On 5/3/23 at 1:54 PM, Licensing Program Analyst (LPA) Malia Thao conducted a case management - deficiencies inspection to address observations made during complaint #24-AS-20230106152902 inspection. LPA explained reason for inspection and met with Administrator Shelly Randel.

During the complaint inspection, LPA observed the signal system devices installed at bedside and in the bathrooms of sampled bedrooms in Memory Care of room #306, 308, 314, and 317 were all inoperable. During interviews, LPA found that staff conduct 30 minute checks on residents and do not use pagers to be able to receive the signal system alert for the memory care residents.

A deficiency is being cited based on LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted and a Plan of Correction was reviewed and developed with the Administrator. Due to technical difficulties, a copy of this report and appeal rights were emailed to Administrator with "read receipt" to confirm receipt of this report.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: 559-470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023
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 05/03/2023 02:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/10/2023
Section Cited

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87303 Maintenance and Operation
(a) The facility shall be...in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
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Administrator will submit proof of written plan to ensure signal system is operating and what will be done to re-implement the signal system for the memory care residents and staff, to include projected completion dates, to CCL by POC due date.
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LPA observed the signal system devices installed at bedside and in the bathrooms of sampled bedrooms in Memory Care of room #306, 308, 314, and 317 were all inoperable. During interviews, LPA found that staff conduct 30 minute checks on residents and do not use pagers to be able to receive the signal system alert for the memory care residents. This 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: Melinda HoffmannTELEPHONE: (559) -341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: 559-470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023
LIC809 (FAS) - (06/04)
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