<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247202428
Report Date: 11/24/2021
Date Signed: 11/24/2021 01:10:25 PM

Document Has Been Signed on 11/24/2021 01:10 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:PARK MERCEDFACILITY NUMBER:
247202428
ADMINISTRATOR:ELINA MOILANENFACILITY TYPE:
740
ADDRESS:3050 M STREETTELEPHONE:
(209) 722-3944
CITY:MERCEDSTATE: CAZIP CODE:
95348
CAPACITY: 125CENSUS: 60DATE:
11/24/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:51 AM
MET WITH:Elina Moilanen, AdministratorTIME COMPLETED:
01:20 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 conducted an unannounced case management visit to the facility. LPA met with Administrator Elina Moilanen and stated the purpose of the visit.

The purpose of the case management visit is to respond an incident report that was submitted to CCL Office incident occurred on 06/07/2021 regarding Resident (R3) going absent without leave (AWOL). Facility staff responded immediately once the facility alarm went off. Staff checked all residents and rooms. Facility staff found R3 at Pizza Hut. R3's Power of Attorney decided to move the R3.

LPA followed up with incident report that occurred on 07/19/2021 and 07/27/2021 regarding medication errors for Resident (R1) and R2.

On 07/19/2021, Staff (S1) provided R1 one tablet of Risperidone 0.5 mg, instead of ½ tablet.

On 07/27/2021, S2 provided R2 with her medication Fentanyl 25mch/hr patch a day earlier.

Per incident reports and Administrator, residents did not have adverse reaction and their primary physicians were notified. Residents were monitored by facility staff. Administrator reported S1 transitioned to another facility position and is no longer a medication technician. Administrator reported S2 quit on 9/9/2021. Due to the medication errors Administrator facilitated a all medication technician training on 10/21/2021.

LPA followed up with incident report that occurred on 08/05/2021 regarding Staff (S3) and S4 were using hoyer lift. Facility will provide training to all caregivers on 12/8/2021 at 1:30p.m.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE: DATE: 11/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/24/2021
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 3
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: PARK MERCED
FACILITY NUMBER: 247202428
VISIT DATE: 11/24/2021
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
26
27
28
29
30
31
32
Deficiencies are cited in LIC809D.

Exit interview was conducted. A copy of this report, LIC809, LIC809-D and appeal rights were provided. The Licensee’s signature on this form acknowledges receipt of these documents.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE:

DATE: 11/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/24/2021 01:10 PM - It Cannot Be Edited


Created By: Lady Cabrera On 11/24/2021 at 12:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: PARK MERCED
FACILITY NUMBER: 247202428

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/24/2021
Section Cited
HSC
1569.312

1
2
3
4
5
6
7
§1569.312 Basic services requirements

Every facility required to be licensed under this chapter shall provide at least the following basic services:
(a) Care and supervision as defined in Section 1569.2.
*This requirement was not met as evidenced by:
1
2
3
4
5
6
7
On 06/07/2021, Licensee met with Resident's (R3) Power of Attorney(POA). On the same date, POA hired one on one for R3 during the waiting period of transitioning her to another facility. Licensee informed POA that the facility was unable to meet R3's needs.

POC-Cleared.
8
9
10
11
12
13
14
The incident occurred on 06/07/2021 resulted in resident R1 going AWOL from the facility. R1 is/was unable to leave the facility unassisted. Resident has a dementia diagnosis.

**This presents an immediate risk to the health, safety or personal rights of the clients in care.
8
9
10
11
12
13
14
Type A
11/24/2021
Section Cited
CCR87465(a)(5)

1
2
3
4
5
6
7
87465 Incidental Medical...(a) A plan for incidental medical and dental care shall be developed by each facility...:(5) The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
On 10/21/2021, Licensee facilitated a all medication technician training. A copy of the training roster was provided to CCL on today's date.

POC-Cleared.
8
9
10
11
12
13
14
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.
8
9
10
11
12
13
14
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 Pidgirny
LICENSING EVALUATOR NAME:Lady Cabrera
LICENSING EVALUATOR SIGNATURE:
DATE: 11/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/24/2021


LIC809 (FAS) - (06/04)
Page: 3 of 3