I found the staff overwhelmingly kind, attentive and caring and the campus beautiful, clean and homelike with lots of activities and generally good meals. However, communication and management responsiveness were inconsistent, staffing (especially in memory care) felt thin at times, and there are reports of cleanliness, odor, pest and maintenance/security issues. I would recommend touring in person and asking pointed questions about staffing, memory-care practices and extra fees before deciding.
Secure, locked units reported by several reviewers
Memory care unit and respite care availability
Helpful, informative tour staff and clear move‑in guidance reported
Family‑friendly visiting policy and social atmosphere
Pets allowed / dog‑friendly in some units
Prompt resolution of some concerns when management is responsive
Housekeeping and housekeeping services offered (though variable)
Multiple meal choices (two entrees per meal reported in some reviews)
Transportation vans and proximity to hospital/shopping
Positive hospice support in some cases
Many reviewers report good value compared with alternatives
Well‑organized activities calendar and opportunities for socialization
Cons
Pest problems reported, including roaches (noted in facility and memory care)
Deferred maintenance and upkeep issues (broken exterior door locks, lighting, parking lot lights)
Understaffing and low staff‑to‑resident ratios (several reports of two aides for many rooms)
Inconsistent or uncaring caregiving; reports of unqualified or overworked staff
Safety and security vulnerabilities from broken locks, poorly lit areas, and wandering residents
Cleanliness lapses in specific units (memory care urine odor, overflowing trash, soiled bedding)
Slow response to call lights and assistance (examples ~30 minutes)
Inconsistent management responsiveness and accountability
Missing valuables / theft concerns reported
Inconsistent food quality—some say limited choices or dietary needs not followed
Pricing concerns: high cost, annual increases, lack of pricing transparency
Extra charges for medication management reported
Poor documentation and communication (missed appointment records, delayed paperwork)
Variable experience across shifts (weekend staff uninformed, front desk not always staffed)
End‑of‑life and hospice care inconsistencies (delayed help, distressing incidents)
Memory care concerns: wandering residents, unsecured rooms, insufficient supervision
Reports of residents not bathed or cleaned promptly, distressing neglect incidents
Inconsistent housekeeping (rooms sometimes not cleaned or sheets not changed)
Some areas under renovation or in need of remodeling (memory care unit cited)
Mixed reviews on suitability for more medically fragile or high‑care residents
Summary review
Overall sentiment for Pacifica Senior Living Merced is highly mixed, with a sizable number of very positive experiences coexisting alongside a number of serious, recurring concerns. Strengths consistently highlighted across many reviews include friendly and caring staff, an active calendar of activities (bingo, music, crafts, outings, chair Zumba, etc.), attractive common areas and an impressive entrance/foyer, and generally spacious, comfortable rooms with useful amenities (kitchenette, fridge/microwave, large closets). Many families report that meals are good — varied, healthy options with salad bars, fresh fruit, and two entrée choices — and that meals, linens, laundry and transportation are included in base pricing. Reviewers frequently praise the social environment, helpful tour staff, on‑site amenities like a salon and pharmacy, and secure locked units for assisted living, and several accounts describe timely, responsive management and staff who go above and beyond.
However, a distinct and significant subset of reviews raises serious operational and safety concerns. Several reviewers report pest problems (explicitly roaches in facility rooms and memory care), deferred maintenance (broken exterior door locks left unfixed, parking lot and exterior lights not repaired), and security vulnerabilities that could directly affect resident safety. Understaffing is a recurrent theme — with reports of very low aide coverage (examples such as two aides for 60 rooms), long call response times (about 30 minutes in one report), and staff who appear overworked or stretched thin. These staffing issues are tied to accounts of inconsistent or uncaring caregiving, delayed assistance during medical or hospice situations, lapses in bathing and hygiene, soiled bedding left unattended, and even a few extreme anecdotes (residents dying alone or hospice unable to secure timely help). Memory care surfaces repeatedly as an area of concern: reviewers cited roaches within memory care, wandering or unsecured residents, urine odor, inadequate supervision, and incidents suggesting the unit may not be suitable for more medically fragile patients.
Cleanliness and maintenance reports are also mixed. Many reviewers describe a clean, well‑kept facility, neat rooms and freshly painted areas; others describe cleanliness lapses ranging from spider webs and overflowing trash to toilets and sinks not cleaned and bedding not changed. This inconsistency suggests variability by unit, shift, or timeframe rather than a uniformly clean or dirty facility. Security and personal property protection concerns arise in a few reports of missing valuables and poor accountability. Relatedly, documentation and communication are inconsistent: some families praise open communication and responsive management, while others report missed or delayed paperwork, poor documentation of incidents, missed appointments, and unreturned calls. Weekend staffing and front desk coverage appear to be variable according to multiple reviews, which contributes to a perception of uneven care and management oversight.
Dining and dietary care are another mixed area. Numerous reviewers praise the food quality, healthy low‑salt options, and inclusion of meals in base fees, while others report limited menu choices, dietary guidelines not being followed, or unsatisfactory dining experiences. Activities programming is often a highlight (many specific activities and events were observed), but a few reviewers found offerings inadequate or that not all residents were engaged. Pricing and billing practices drew frequent criticism: several reviewers described the community as expensive, noted annual price increases, cited opaque or point‑based pricing structures, and reported extra charges such as fees for medication management. This combination of high cost and inconsistent care quality is a recurring source of frustration for families.
A clear pattern emerges of variability: many families have excellent experiences and feel their loved ones are well cared for in a warm, active environment; at the same time, a non‑trivial number of reviewers report severe lapses in maintenance, hygiene, staffing, safety and communication. Positive and negative reports often coexist within the same facility, which points to inconsistent standards or fluctuating conditions across shifts, units (especially memory care), or over time. Specific red flags to investigate in person include pest control records and recent remediation, staffing ratios and turnover (including coverage on nights and weekends), maintenance logs for doors and outdoor lighting, security and visitor policies, protocols for hygiene and end‑of‑life care, incident documentation practices, and transparent pricing/fee schedules (including any medication management charges).
In summary, Pacifica Senior Living Merced offers many of the desirable features families seek — warm staff, a robust activity program, comfortable and accessible rooms, and appealing communal spaces — but there are important and recurring concerns about staffing adequacy, maintenance, cleanliness (particularly in memory care), safety and communication. Prospective families should balance the many positive reports against the negative ones by conducting a focused, in‑person visit: ask for recent inspection and pest control records, request staffing ratios and sample daily schedules for the unit of interest, verify how the facility handles medication management and hospice needs, check security mechanisms and front‑desk coverage after hours, and obtain clear, written pricing and fee policies. These targeted checks will help determine whether the strong positives in many reviews are representative for the specific unit and time period relevant to your loved one, or whether the facility’s inconsistent issues might pose unacceptable risk.
Location
About Pacifica Senior Living Merced
Pacifica Senior Living Merced sits in Merced, California, and has a warm, home-like feeling with several choices for older adults, whether someone needs a little help each day or more focused care for memory loss or medical problems. The Craftsman-style building stands out with a turret and a covered entrance with white pillars and benches, and it's got walkways and green landscaping that make the outdoors welcoming for taking a stroll or sitting with friends. Inside, the décor feels cozy and stylish, with fireplaces, comfortable chairs, tasteful artwork, and soft lighting in common areas. Memory Care spaces have special touches, like a coffee bar, elegant staircase, and sitting areas with big windows and lots of natural light. The studio rooms in Memory Care feel safe, with big windows and simple comfort for those who live there.
The dining rooms look a bit different for each type of care, with an elegant room for Memory Care that's both cheerful and stylish, and restaurant-style dining and comfy seats for those in Assisted Living, so meals often feel like a special occasion. There are well-lit hallways, handrails for safety, elevators for easy access, and artwork on the walls to brighten the building. Pacifica Senior Living Merced has indoor and outdoor spaces for relaxing, a fitness area, coffee bars, and courtyards where residents can socialize or enjoy quiet time. Every resident has choices between studio, 1-bedroom, and 2-bedroom apartments, all with traditional furnishings and thoughtful amenities to make it easier to live independently or with help.
The staff are known for being welcoming, helpful, and attentive. Nurses and caregivers support residents 24/7, and they tailor care to each person's needs, including for memory impairment, Alzheimer's, dementia, and chronic medical issues like diabetes or stroke. Memory Care uses unique programs and fewer hallways, so residents don't get confused, and special activities help keep minds active. There's also a DayOut Adult Day Health Care option where seniors can get hot meals, therapy, nursing, and social services, with transportation provided during the week. For those who need a short stay after surgery or if a caregiver takes a break, respite care is available, as well as hospice services.
Residents get help with daily activities like bathing, dressing, and medication, and there are housekeeping and transportation services. The community doesn't allow indoor smoking, welcomes pets, and offers vegetarian meals. Activities happen daily, from social and recreation programs to entertainment and devotional services, to help people stay connected and engaged. Residents can use onsite beauty services and take part in group or individual activities. Pacifica Senior Living Merced has a relaxed Californian lifestyle, and while things look elegant, the real focus is making everyone feel safe and comfortable. The building is kept clean, even at the back doors, and the facility stays open all day and night to help when needed. A dedicated shuttle helps residents get around town, and the goal is always to support health, happiness, and independence, whatever level of care a resident might want.
Founded in 2008 and headquartered in Redding, California, Northstar Senior Living has established itself as one of the premier providers of senior living management and consulting services in the United States. Under the leadership of President and CEO Rick Jensen, who co-founded the company, Northstar has built a reputation for excellence in senior care management through its commitment to setting industry gold standards. The privately owned company operates approximately 40-51 communities across nine states, offering comprehensive management services that span the full spectrum of senior living operations.
People often ask...
Pacifica Senior Living Merced offers competitive pricing, with rates starting at a cost of $5,094 per month.
Pacifica Senior Living Merced offers assisted living and memory care.
There are 34 photos of Pacifica Senior Living Merced on Mirador.
The full address for this community is 3420 R St, Merced, CA, 95348.
Yes, Pacifica Senior Living Merced offers respite care.
Respite care in assisted living communities provides temporary, short-term relief for primary caregivers by offering professional care for their loved ones. It allows individuals to stay in an assisted living community for a limited time, giving caregivers a break while ensuring residents receive necessary support and assistance with daily activities.
State of California Inspection Reports
91
Inspections
19
Type A Citations
26
Type B Citations
6
Years of reports
27 Jun 2025
27 Jun 2025
Investigated the allegation that staff did not ensure residents could receive personal calls; found a landline and a cell phone available, with staff assisting residents to use them on request. Found not enough evidence to determine whether the allegation occurred or not, no deficiencies cited, and an exit interview was conducted.
17 Apr 2025
17 Apr 2025
Found the residence clean, comfortable, and well maintained, with secure medications, proper food storage, and up-to-date staff and resident records. Identified one deficiency and noted that updated administrative documents should be submitted by the specified date.
§ 9058
§ 87456(a)(3)
17 Apr 2025
17 Apr 2025
Investigated the allegation that staff do not follow infection control requirements; found that infection control practices were being followed at the site. Noted that one resident was able to empty their own ostomy bag and another resident was receiving hospice care.
17 Apr 2025
17 Apr 2025
Found that staff did not respond to residents' calls in a timely manner, with some calls unanswered for more than 20 minutes and others for over an hour. Identified that a resident's physician's report had not been updated since 2018.
20 Mar 2025
20 Mar 2025
Reviewed a case management visit where a licensing analyst spoke with the administrator, toured the site, and observed residents having breakfast and others resting, with 20 residents on hospice care noted. Amended an earlier deficiency finding, requested the administrator certificate, updated the hospice waiver, and set 03/21/2025 at 5:00 PM PT to submit required files.
12 Mar 2025
12 Mar 2025
Identified that staff did not provide an updated resident reappraisal after a change in condition.
05 Mar 2025
05 Mar 2025
Found insufficient evidence to prove or disprove neglect/lack of care and/or supervision resulting in a resident's personal rights violation.
05 Mar 2025
05 Mar 2025
Investigated a complaint and reviewed records, identifying that the records for two residents were not up to date. A deficiency was issued.
§ 87506(a)
26 Nov 2024
26 Nov 2024
Found the allegation that staff did not ensure an insect issue was being properly addressed for residents in care, after observing a cockroach infestation in a resident's room.
17 Oct 2024
17 Oct 2024
Identified a Decision and Order excluding a staff member from all premises and not allowed to be employed, effective 05/31/2024. Found no deficiencies were observed.
04 Sept 2024
04 Sept 2024
Found no deficiencies identified; safety devices and detectors were functional, living areas were clean and well lit, medications secured, and resident and staff records complete.
04 Sept 2024
04 Sept 2024
Inspection found facility in compliance with regulations, with all areas clean, well-maintained, and properly equipped. No deficiencies were identified during the visit.
23 Apr 2024
23 Apr 2024
Identified safety concerns at the site, including an expired centrally stored medication kept in the medication cart with other meds and several bathrooms lacking tight-fitting covers. Overall, areas examined were clean and well-maintained with adequate food and supplies, and residents in the memory care area were participating in activities.
23 Apr 2024
23 Apr 2024
Confirmed deficiencies related to expired medication and improper storage of supplies during the annual inspection conducted by the Licensing Program Analyst.
§ 9058
20 Mar 2024
20 Mar 2024
Identified five specific allegations: delayed responses to pendant alarms, missed medications, not following a resident’s care plan, multiple falls due to transfer delays, and failure to provide a signed copy of the resident assessment to the authorized representative. Evidence from records and interviews showed long response times, medication omissions, transfer delays causing falls, and missing documentation.
20 Mar 2024
20 Mar 2024
Confirmed multiple allegations of neglect, including delayed response times to resident calls for assistance, missed medications, and failure to follow care plans.
§ 9058
§ 87506(a)
§ 87468.2(a)(4)
28 Dec 2023
28 Dec 2023
Found no immediate health or safety concerns after a tour; requested additional information regarding an incident on 12/19/2023; no deficiencies cited; exit interview conducted.
28 Dec 2023
28 Dec 2023
Conducted an inspection, found no deficiencies, requested additional information on a specific incident.
§ 87507(e)
11 Oct 2023
11 Oct 2023
Found no deficiencies; safety systems were functional, spaces were clean and adequately lit, medications were secured, and resident records were complete, with three residents receiving hospice care.
11 Oct 2023
11 Oct 2023
Found no deficiencies during the inspection. All areas of the facility met required standards for safety, cleanliness, and resident care.
04 May 2023
04 May 2023
Identified debris and dead bugs in common areas and some resident bedrooms, and food debris in the dining area. Also found unsecured cleaning products under the sink in memory care, a missing non-slip mat in a shower, outdated disaster/emergency drill records, and violations were issued.
§ 87303(e)(5)
§ 87303(a)
§ 87309(a)
§ 1569.695(c)
04 May 2023
04 May 2023
Confirmed deficiencies were found during the inspection, including cleanliness issues in common areas and resident bedrooms, as well as inadequate recordkeeping for disaster drills.
§ 87457(a)(3)
§ 87468.2(a)(4)
§ 87465(a)
§ 87464(d)
§ 87411(a)
03 May 2023
03 May 2023
Identified that the call signal system may show extended times due to a technical issue, but staff typically responded within five minutes, and meals are prepared hot though they can cool before delivery and are reheated if needed.
Identified that the resident has no authorized representative on file, though other contacts exist and an appointed agent under an advance health care directive; notification about incidents was provided.
03 May 2023
03 May 2023
Identified a deficiency where signal system devices at bedside and in bathrooms in memory care rooms were inoperable and staff did not use pagers to receive alerts for memory care residents.
§ 87303
03 May 2023
03 May 2023
Confirmed extended response times and reheating of cooled meals, but found no evidence to substantiate the allegations. Identified lack of authorized representative on record, but determined that facility did not fail to notify authorized representative of the incident.
§ 87303(a)
02 Mar 2023
02 Mar 2023
Identified expired foods in the home’s refrigerator and freezer and insects in several resident rooms. Found elevator-maintenance concerns unfounded; allegations of a resident fracture and insufficient staffing lacked evidence, and no resident funds were found missing; the refrigerator appeared clean.
§ 80087(a)(1)
§ 87555(b)(8)
02 Mar 2023
02 Mar 2023
Confirmed expired foods and insects in resident rooms. Elevator maintenance complaint was unfounded. Fracture and staffing allegations were inconclusive.
§ 87303(f)(3)
§ 87465(i)
29 Sept 2022
29 Sept 2022
Found multiple unusual incidents involving residents, including unclear Tylenol amount leading to ambulance transport and ongoing medication administration by staff; a minor skin tear; a health and safety issue with no follow-up needed; and an absence without leave with police involvement after a door issue and supervision lapse. A civil penalty was cited, and an exit interview with required documents occurred.
§ 1569.312
29 Sept 2022
29 Sept 2022
Found COVID-19 guidelines were in place, entry checks with temperature screening, and masks worn by staff and residents; medications, food, cleaning and PPE supplies were adequate, and emergency contact information was up to date. Noted deficiencies.
29 Sept 2022
29 Sept 2022
Identified incidents prompted follow-up on resident health and safety concerns, including a resident going missing temporarily.
29 Sept 2022
29 Sept 2022
Inspection identified deficiencies and required forms to be submitted by a specific deadline.
§ 87309(a)
§ 87303(a)
22 Jul 2022
22 Jul 2022
Investigated a complaint that residents could not make or receive calls because the phone line was not working. Found the phone line was repaired on 7/18/2022 and calls were working on 7/19/2022 and 7/22/2022, so the complaint was unfounded.
22 Jul 2022
22 Jul 2022
Investigated and found that residents were able to make and receive calls after the phone line was repaired by the service provider.
26 Apr 2022
26 Apr 2022
Identified deficiencies in several areas during an unannounced annual inspection and reviewed multiple special incident reports to obtain additional information.
26 Apr 2022
26 Apr 2022
Identified deficiencies in various areas of the facility during the inspection.
20 Apr 2022
20 Apr 2022
Reviewed a death report and requested records by 4/21/2022; met with the executive director due to the administrator’s unavailability. Found no deficiencies; a follow-up was planned after records and interviews were conducted.
20 Apr 2022
20 Apr 2022
Found the allegation that COVID-19 protocol was not followed unsubstantiated after interviews and records review. Observed precautionary measures at entry on 02/02/2022 and again today.
20 Apr 2022
20 Apr 2022
Found the allegation of inadequate staffing to meet residents' needs unfounded. During a Covid-19 outbreak on 01/14/2022, staff continued to be hired and focused on resident care.
20 Apr 2022
20 Apr 2022
Found that the allegation that staff behaviors posed a risk to residents was unsubstantiated, and that the allegations that residents sustained falls, residents were left soiled for extended periods, and staff stole residents’ medications were also unsubstantiated.
20 Apr 2022
20 Apr 2022
Found no evidence to support the allegations that bedridden residents were not turned every two hours, that timely assistance with incontinence was not provided, or that roaches were present.
20 Apr 2022
20 Apr 2022
Investigated complaints found the earlier claim of lack of supervision causing a resident fall to be unfounded; however, the second complaint about unmet care needs, laundry services, cold meals, and pests was found valid.
20 Apr 2022
20 Apr 2022
Reviewed allegations of care needs, laundry service, meal temperature, and pests. Care needs and cold meals were substantiated, while pests were unsubstantiated.
§ 87309(a)
§ 87303(a)
08 Feb 2022
08 Feb 2022
Identified concerns about governance by the licensee’s governing body, administrator qualifications and duties, personnel requirements and operations, basic services and supervision, incidental medical and dental care, personal rights, and maintenance and operation, discussed with the licensee representative.
08 Feb 2022
08 Feb 2022
Identified issues and concerns with various aspects of facility operation were discussed in an informal office meeting with the Licensee Representative, Regional Manager, and licensing staff.
02 Feb 2022
02 Feb 2022
Identified that no new administrator had been hired after the prior administrator transferred, and that no notice had been received to date. Reviewed the January 12, 2021 AWOL incident where a resident left around 3 a.m., was located off-site by police, and was reassessed as needing memory care, with a physician's report stating the resident cannot leave unassisted.
02 Feb 2022
02 Feb 2022
Reviewed unannounced visit findings, including a resident going AWOL and missing briefly before being found and returned to the facility.
28 Dec 2021
28 Dec 2021
Investigated a complaint that a resident sustained pressure injuries while in care and another claim about odor; found the pressure injuries claim unfounded and the odor complaint unsubstantiated.
28 Dec 2021
28 Dec 2021
Found conflicting information about a resident's ability to leave unassisted: a physician's assessment dated 04/28/2021 allowed unassisted departure, while a conservator stated the resident cannot leave unassisted as of 11/30/2021. An AWOL incident occurred on 11/06/2021.
28 Dec 2021
28 Dec 2021
Investigated an allegation of residents with pressure injuries, but found it to be unfounded. Also investigated an allegation of staff not keeping the facility odor-free, but it was unsubstantiated.
28 Dec 2021
28 Dec 2021
Confirmed allegations of a resident going AWOL on a specific date, prompting the need for an update to their Needs and Services report.
11 Oct 2021
11 Oct 2021
Investigated an incident from 07/13/2021 where a resident was hit by a branch and became stuck. Noted ongoing adherence to safety and infection-control measures, including mask use, adequate supplies, and up-to-date emergency contacts; deficiencies were cited.
11 Oct 2021
11 Oct 2021
Inspection identified COVID-19 safety measures in place and sufficient supplies. Incident involving a resident being hit by a branch was followed up on. Deficiencies were cited and corrective actions required.
§ 87303(a)
§ 87412(a)(2)
01 Oct 2021
01 Oct 2021
Determined that the resident's designated representative was not informed about the resident receiving the first COVID-19 vaccine dose, and that the resident's room was not cleaned. Found that pests were present in the resident's room and that staff did not ensure the resident took medications as prescribed, while the allegation that staff did not follow physician orders was unfounded.
01 Oct 2021
01 Oct 2021
Confirmed lack of communication with resident's representative and failure to ensure cleanliness of resident's room. Found allegations of staff not following physician's orders, pests in resident's room, and lack of medication administration unsubstantiated.
§ 87411(d)(3)
09 Aug 2021
09 Aug 2021
Determined that the resident's Pre-Admission Appraisal was completed by staff and a relative without the resident's participation. Determined that the resident slept in a recliner at night because appropriate assistance was not provided.
§ 87466
§ 87457(a)
09 Aug 2021
09 Aug 2021
Confirmed allegations of not involving the resident in the pre-admission appraisal and not providing appropriate assistance at night after reviewing interviews, observations, and records.
14 Jul 2021
14 Jul 2021
Identified that a case management visit offered technical assistance and recommended providing residents' personal belongings and immediate items—such as dentures, glasses, hearing aids, and a medication list or medications—when they are transported to the hospital.
14 Jul 2021
14 Jul 2021
Identified that the allegation that staff delayed responding to call buttons, sometimes up to 90 minutes, was supported by interviews and call-button records, with staff citing short staffing and competing duties as factors.
14 Jul 2021
14 Jul 2021
Investigated found that the resident’s fall was not caused by lack of care or supervision, and the allegation that staff did not send the resident’s medication list to the hospital could not be proven. A civil penalty of $250 was assessed.
§ 87465(c)(2)
14 Jul 2021
14 Jul 2021
Confirmed delayed response times to resident call buttons due to staffing shortages.
§ 1569.312
§ 87211
23 Jun 2021
23 Jun 2021
Found the complaint alleging concerns about a resident's health status and level of care unfounded after reviewing medical records and interviewing staff; the complaint was dismissed.
23 Jun 2021
23 Jun 2021
Investigated complaint allegations were found to be unfounded and therefore dismissed.
§ 87468.1(a)(8)
§ 87303(a)
09 Jun 2021
09 Jun 2021
Found an incident on 04/25/2021 in which one resident struck another on the jaw; staff intervened, the resident who was struck was evaluated and taken to the hospital for evaluation, and both residents were doing well.
09 Jun 2021
09 Jun 2021
Found two incidents on 03/23/2021 and 05/16/2021 where a resident went AWOL despite a physician’s order that they could not leave unassisted, marking a second violation in 12 months and resulting in a $500 civil penalty.
§ 1569.312
09 Jun 2021
09 Jun 2021
Identified deficiencies tied to a 03/23/2021 AWOL incident in which a resident walked away after staff received a call. Conducted an exit interview with the administrator.
§ 1569.312
09 Jun 2021
09 Jun 2021
Confirmed incident of resident going AWOL on two separate occasions resulting in a civil penalty assessment of $500.
§ 87411(a)
26 May 2021
26 May 2021
Investigated an unusual incident report about a resident's health and safety check following incidents in March and May 2021. Requested medical and admission-related records.
26 May 2021
26 May 2021
Investigated an unusual incident on 03/21/2021 involving a resident's health and safety check. Requested physician report, reappraisal/assessment, and admission agreement.
26 May 2021
26 May 2021
Investigated incident reports submitted to address health and safety concerns related to a resident. Requested documentation related to resident assessments and agreements from the facility.
05 May 2021
05 May 2021
Identified follow-up on health and safety checks for two residents after an unusual incident; requested admission agreement, physician's report, narratives, and staff contact information by 5/7/2021.
05 May 2021
05 May 2021
Investigated a health and safety concern involving two residents, followed up on their well-being, and requested records to be submitted by 5/7/2021.
23 Apr 2021
23 Apr 2021
Investigated a health and safety follow-up after a resident's change of condition, conducted by phone due to COVID-19 precautions. Requested submission by 4/27/2021 of the resident's admission agreement, physician's notes and orders, assessments and evaluations, a medication list and centrally stored medication forms, and staff contact information.
05 May 2021
05 May 2021
Found that a resident missed a morning prescribed medication dose because the medication was misplaced, and staff were written up and retrained. Determined this was the third violation within twelve months and a civil penalty was assessed.
23 Apr 2021
23 Apr 2021
Investigated the medication error that occurred on 03/23/2021. Requested submission of records, including the resident's admission agreement, physician's report and orders, medication list and Centrally Stored Medication forms, staff phone contact information, and medication technician communication notes, by 04/27/2021.
05 May 2021
05 May 2021
Found deficiencies in incident medical and dental care and assessed a civil penalty for repeated violations.
25 Mar 2021
25 Mar 2021
Found that staff administered the wrong medication to a resident, resulting in a double dose, with monitoring and no adverse reactions. Identified a second violation within 12 months for failure to meet rules on incidental medical care, and assessed a civil penalty of $250.
23 Apr 2021
23 Apr 2021
Confirmed an incident involving a medication error and retraining of staff in response to a health and safety check.
25 Mar 2021
25 Mar 2021
Identified medication error resulted in double dosage for resident, a second violation within 12 months leading to a $250 civil penalty.
04 Mar 2021
04 Mar 2021
Identified a violation of residents' personal rights after an unannounced case management-deficiencies visit conducted by phone due to COVID-19, with findings supported by staff statements and records.
04 Mar 2021
04 Mar 2021
Confirmed an allegation of not meeting personal rights of residents during an unannounced deficiencies visit.
28 Jan 2021
28 Jan 2021
Investigated a health and safety follow-up after a resident incident by phone due to COVID precautions. Requested records such as the resident admission agreement, staff contact information, and the police report number; conducted an exit interview with the administrator.
28 Jan 2021
28 Jan 2021
Concerns were raised and investigated regarding an unusual incident/injury that occurred on a specific date which prompted a follow-up health and safety check of the residents.
17 Nov 2020
17 Nov 2020
Found that the allegation that residents' medications were not dispensed correctly in March was supported by records and interviews, with the inquiry conducted by telephone due to COVID-19 precautions.
17 Nov 2020
17 Nov 2020
Confirmed incorrect dispensing of medications based on records review and interviews.
§ 87465
09 Oct 2020
09 Oct 2020
Identified a health and safety concern involving a resident after an incident on 10/04/2020, reported on 10/07/2020. Requested submission of a recent physician report and discharge papers by 10/13/2020, and emailed the original LIC809 for signature with submission by 10/12/2020.
09 Oct 2020
09 Oct 2020
Found deficiencies in health and safety practices during the inspection.
30 Apr 2020
30 Apr 2020
Found allegations were unfounded after discussion with facility staff, as resident's family chose to move them out and regular staff checks were conducted.
08 Apr 2020
08 Apr 2020
Investigated allegations regarding the facility; determined no sufficient evidence to prove violations occurred. Conducted interviews and records review, and communicated findings via telephone and email.
§ 87465
11 Mar 2020
11 Mar 2020
Reviewed incidents involving two residents on 03/03/20, no deficiencies were found in the resident's records.
§ 87468.1(a)
21 Jan 2020
21 Jan 2020
Found no deficiencies in relation to an incident involving a resident leaving the facility.
01 Nov 2019
01 Nov 2019
Inspection found no hazards, medications were properly stored and administered, and staff had necessary clearances.