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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247206921
Report Date: 05/05/2021
Date Signed: 05/19/2021 11:45:53 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 - OtherUNANNOUNCEDTIME BEGAN:
03:03 PM
MET WITH:Tracy Seibert, Memory Care DirectorTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Lady Cabrera contacted Tracy Sibert, Memory Care Director by phone due to COVID-19 and pre-cautionary measures. Administrator Tyler Wilds designated Tracy Seibert to meet with LPA. LPA spoke with Tracy Seibert.

On 04/30/2021, 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 (R1) and R2 and to obtain additional information.

LPA requested the following documents and records:

1. Resident’s Admission Agreement

2. Physician's Report (LIC602A)

3. Facility Narratives

4. Staff contact information

The above documents shall be submitted to CCLD by 5/7/2021.

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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