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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600255
Report Date: 05/22/2025
Date Signed: 05/22/2025 02:58:29 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/10/2024 and conducted by Evaluator Gregory Clark
COMPLAINT CONTROL NUMBER: 15-AS-20240410105909
FACILITY NAME:MERCY RETIREMENT & CARE CENTERFACILITY NUMBER:
015600255
ADMINISTRATOR:DAVIS, JOSEPHINE IFACILITY TYPE:
741
ADDRESS:3431 FOOTHILL BOULEVARDTELEPHONE:
(510) 534-8540
CITY:OAKLANDSTATE: CAZIP CODE:
94601
CAPACITY:160CENSUS: 78DATE:
05/22/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Kathleen McCarron, AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff did not provide adequate supervision resulting in a resident sustaining multiple falls
INVESTIGATION FINDINGS:
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On 05/22/2025 at 2:00 PM, Licensing Program Analysts (LPAs) Greg Clark and Ardalan Gharachorloo arrived unannounced to deliver findings in regard to the allegation above. LPA met with Kathleen McCarron, Administrator and explained the purpose of the visit.

During the course of the investigation the department interviewed W1, facility staff, facility residents, hospice staff and W2. The department also reviewed R1’s medical records.

R1 was admitted to the facility on 12/28/23 because his health was deteriorating due to prostate cancer. R1 was on hospice at time of admission.

Review of R1’s medical records document that R1 sustained approximately 7 falls within a 13-day span resulting in multiple injuries and at least two hospital visits. Also documented in R1’s medical records were that he was a fall risk, and that the facility should take measures to monitor his level of care to mitigate the risk of injuries from falls.
***CONTINUES ON 9099C***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20240410105909
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: MERCY RETIREMENT & CARE CENTER
FACILITY NUMBER: 015600255
VISIT DATE: 05/22/2025
NARRATIVE
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***CONTINUES FROM 9099***

The department interviewed staff who stated they were aware that R1 was a fall risk but were never given any instructions from management to change the level of care they were providing to R1. Staff stated that they performed random checks on R1 every hour or two hours at most or more frequent whenever they got the chance but there was no formal monitoring plan in place. The only measures taken were that R1’s bed was lowered, and a fall mat was placed on the floor beside the bed. Multiple interviews with S1 revealed that fall preventative measures did not change and were the same beginning after R1’s first fall to the last fall incident.

Based on the department’s observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted, a copy of this report and appeal rights provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20240410105909
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MERCY RETIREMENT & CARE CENTER
FACILITY NUMBER: 015600255
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/20/2025
Section Cited
CCR
87463
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(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition...

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Facility to review resident’s assessments for accuracy and update needs and services plans as needed. In addition, the facility will develop a procedure for how to they will disseminate changes from the reappraisals with direct care staff and submit it to CCL by POC date.
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(b) The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person.
Based on observation the licensee did not comply with the section cited above. R1 had multiple falls over a 2-week period and the facility never updated his appraisal.
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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.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3