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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247206921
Report Date: 05/05/2021
Date Signed: 05/07/2021 08:22:41 AM

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: 69DATE:
05/05/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:33 PM
MET WITH:Tracy Seibert, Memory Care DirectorTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lady Cabrera conducted a subsequent Case Management visit to discuss information obtained from the initial visit conducted on 04/23/2021. Case Management was conducted via telephone due to COVID-19 and pre-cautionary measures. Administrator Tyler Wilds designated Tracy Seibret, Memory Care Director to meet with LPA. LPA spoke with Tracy Seibertt.

During the investigation, Resident (R1) missed her morning prescribed medication dose due to medication being misplaced. Staff (S1) was written up and retrained on medication error immediately.

Based on the LPAs interview and records review, the Licensee did not meet California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87465(c)(2) Incidental Medical and Dental Care. Deficiency is being cited on the attached LIC 809-D.

This is a third violation within the last twelve (12) months. First violation occurred on 11/17/2020 and second violation occurred on 03/25/2021. Civil Penalty in the amount of $250.00 is assessed.

Exit interview conducted with Memory Care Director and was provided with the LIC809, LIC809-D, LIC421FC and Appeal Rights.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: PACIFICA SENIOR LIVING MERCED
FACILITY NUMBER: 247206921
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/19/2021
Section Cited

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87465 Incidental Medical...(c)...physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication...(2)Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidenced by:
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Based on records review and interviews, the Licensee did not meet the Incidental Medical Care, which poses an Immediate Health, Safety and Personal Rights risks 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: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2021
LIC809 (FAS) - (06/04)
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