247206921-5-18-2021-24-AS-LCAA-C35UYN-20210518160014

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 247206921
Report Date: 04/23/2021
Date Signed: 05/18/2021 04:00:16 PM

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 MERCED		FACILITY NUMBER:	247206921
ADMINISTRATOR:	TYLER WILDS		FACILITY TYPE:	740
ADDRESS:	3420 R ST		TELEPHONE:	(209) 580-6124
CITY:	MERCED	STATE: CA	ZIP CODE:	95348
CAPACITY:	93	CENSUS: 72	DATE:	04/23/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	02:55 PM
MET WITH:	Tracy Seibert, Memory Care Director		TIME COMPLETED:	03:25 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Lady Cabrera contacted Tracy Sibert, Memory Care Director by phone due to COVID-19 and pre-cautionary measures.

On 03/18/2021, Community Care Licensing received the Unusual Incident/Injury Report. The purpose of the phone call is to follow-up on the health and safety check of the resident and to obtain additional information regarding resident's change of condition.

LPA requested the following documents and records:

1. Resident’s Admission Agreement

2. Physician's Report (LIC602A) and physician's orders

3. Resident's facility assessment and evaluations

4. Medication list and Centrally Stored Medication forms

5. Staff phone contact information

The above documents shall be submitted to CCLD by 4/27/2021.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady Cabrera	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 1