Mercy Retirement & Care Center

Review of R1’s medical records documents that R1 sustained approximately 8 falls once a month, resulting in multiple injuries and at least 8 hospital visits. Also documented in R1’s medical records were that R1 was a fall risk, however after reviewing R1 care plan shows fall injuries were counted for and the facility does have a fall intervention in place including but not limited to frequent check in every two hours, clutter free, assistive devices are available in good repair, the bed in low position, half bed rails and with soft matting around the bed. According to the SOC 341 obtained by the department, RP stated that the hospital staff found R1 on the hospital floor. R1 was sent out on 11/28/2025 by the facility via ambulance with an unwellness fall, and it was determined that any fall R1 experiences needs to be sent to the hospital due to R1's care plan. Before sending out, R1 was assessed, and the record shows that R1 did not have any injuries, but due to R1's conditions. The facility followed procedure and called 911 to transport R1 to the hospital, and informed the family member that R1 was sent out. LPAs interviewed S1, S2, S3, and S4; all confirmed that they did carry out the care prevention plan for R1. This agency has investigated the complaint alleging residents sustain unexplained injury while in care. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview conducted, a copy of this report provided.

On 3/11/2026 at 10:45 AM, Licensing Program Analyst (LPA) Y. Brown conducted an unannounced annual 1-year required inspection. LPA met with Executive Director Kathleen McCarron and explained the purpose of the visit. The administrator currently holds a certificate (# 7002969740 ) that expires on 2/3/2028. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, and back yard. All indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature for clients is maintained at 73 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in a random sample of residents rooms were measured at 118.3, 115.3, and 107.4 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. The supply of extra hygiene was available for residents. Smoke detectors and carbon monoxide combination were in operating condition during visit. Fire extinguisher was last purchased on 3/2/2026. First aid kit was observed to be complete. LPA reviewed five (5) staff and five (5) client records. LPA reviewed a sample of medication. Continued on LIC809C. 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 Continued from LIC809. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 3/18/2026: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan No deficiencies cited during today's visit. Exit interview conducted with Kathleen and a copy of this report provided.

On 9/15/2021 at 11:15AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Case Management Inspection in regards to an incident report received on 9/2/2021. LPA met with Administrator, Tamra Marie Tsanos. Incident report reveal that R1 was given incorrect dosage of Hydrocodone than the physician's order. Interview with S1, S2, and S3 revealed that the physician's order two different dosage for Hydrocodone with one being a PRN medication. It was discovered that PRN medication have been given incorrectly to R1. S2 stated that facility have implemented new procedures and guidelines for medication administration. Disciplinary action was given to the staff that was involved. Routine audits of medication have been implemented and staff will be provided refresher course related to medication administration. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 . Failure to correct deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.

On 03/16/22 at 2:50 p.m. Licensing Program Analyst (LPA) G. Clark arrived unannounced to conduct Infection Control Inspection. LPA met with Administrator, Tmara Tsanos and Vivenne Campbell explained the purpose of the visit. During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

***CONTINUE FROM 9099*** R1 was also prescribed a daily aspirin. LPA observed that the PRN medications were all signed off as administered by the hospice nurses. From 4/01/24 until the time of R1’s passing on 4/10/24 he was given a total of 22 PRN medications for pain, restlessness, and anxiety. LPA observed that the MARs for the PRN medications were filled out according to regulation. Allegation: staff did not inform residents responsible party of incidents in a timely manner The department interviewed W2. W2 stated that she visited R1 regularly at the facility. W2 had no complaints regarding facility staff stating staff took care of R1 and provided him with sufficient supervision. W2 further stated that staff always instructed R1 to be careful when walking and would check on R1 all the time. LPA was unable to reach the W1 or W2 for further investigation as which incidents weren’t reported in a timely manner. This agency and the department have investigated the complaints alleging staff did not administer medications as prescribed, and staff did not inform residents responsible party of incidents in a timely manner. We have found that the allegations were unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted, a copy of this report provided.

Facility staff, S1, S2 and S3 also stated that they have never heard facility staff yell at the residents. S1 stating that if she ever did hear staff yell at the residents would be a disciple issue and that has not happened. This agency has investigated the complaint alleging staff yelled at residents in care. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview conducted, a copy of this report provided.

On 4/16/25 at 2:30 p.m., Licensing Program Analyst (LPA) Greg Clark and Ardalan Gharachorloo arrived unannounced to conduct a case management visit on this date to provide technical assistance. LPAs received special incident report regarding numerous medication errors that occurred on 4/1/25 for 23 residents. The errors happened when the facility was switching pharmacies. LPAs spoke with Executive Director and reviewed the report with her. LPAs also toured the medication room and observed the current system of dispensing medications and storage. None of the residents experienced any side effects from the missing medications most of which where over the counter medications. Interview with the Executive Director revealed that the issue has been resolved and there have been no further medication errors occurred. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 01/05/2026 at 1:30PM, Licensing Program Analysts (LPAs) Andrew Christy and Kelly Nguyen conducted a Case Management regarding documentation during a complaint investigation. LPAs explained the nature of the case management to Kathleen McCarron, executive director. During the complaint investigation, LPAs conducted file review for a resident (R1) to ensure reporting requirements were being met. In the file, LPAs did not see incident reports for a fall in November and a wound being treated in December, though executive director claims they were submitted. LPAs requested these documents be sent to them by 01/07/2026, as well as the fax confirmation that they normally include with all sent incident reports. In addition, LPAs request the care notes done for the patient to be sent on 01/16/2025, covering the dates of 01/05/2026-01/15/2026. No deficiencies cited during visit. Exit interview conducted and a copy of this report was made available to the executive director.

**CONTINUES FROM 9099** LPAs interviewed S1. S1 stated that R1 is currently on hospice and receiving the end of life care. There was a period of time that R1 did not eat for five days. S1 further reported that R1 often refuses to open her mouth to accept food, drink and medications. S1 also reported that staff make every effort to encourage R1 eat and drink but are often unsuccessful. S1 is confident that R1 is receiving an adequate amount of food in a timely manner as tolerated. This agency has investigated the complaint alleging s taff did not provide resident food in a timely manner and staff are not providing resident with an adequate amount of food. We have found that the complaint was unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted, a copy of this report provided.

On 4/16/25 at 11:00 a.m., Licensing Program Analyst (LPA) Greg Clark and Ardalan Gharachorloo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Kathleen McCarron and explained the purpose of the visit. LPA toured the facility including but not limited to 5 residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 70 degrees F. The hot water temperature in the art room was measured at 113.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 4/25/25. Emergency Disaster Plan was last signed on 9/12/24. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 4/15/25. LPAs reviewed 5 residents records and 5 staff records, and all were complete. LPAs also reviewed a sample of resident’s medications. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

Currently the facility staff provide R1 access to the laptop as tolerated by the resident. This agency has investigated the complaint alleging staff are not allowing a resident in care access to their personal property. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.

Allegation: Staff do not ensure that resident's dietary needs are met. Based on file review, observation and interviews this allegation is unsubstantiated. Allegation: Staff are not following resident's feeding plan. Based on file review, observation and interviews this allegation is unsubstantiated. This agency has investigated the complaint alleging staff do not ensure that resident's dietary needs are met and staff are not following resident's feeding plan. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview conducted, a copy of this report provided.

On 10/03/24 at 11:15 a.m., Licensing Program Analyst (LPA) Greg Clark and Ardalan Gharachorloo arrived unannounced to deliver amended report for the LIC9099 dated 9/12/24. LPA met with Elvira Suciu, Resident Care Director (RCH) and explained the purpose of the visit. Amended report delivered to RCH. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 4/12/24 at 11:00 AM, Licensing Program Analyst (LPA) Greg Clark conducted a Health & Safety inspection as a result of a priority 1 complaint. LPA met with Elvia Suciu, Resident Care Director and explained the purpose of the visit. LPA toured facility including but not limited to the apartments, bathrooms, common area, kitchen, and outdoor area. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Refrigerator temperature was observed at xx degrees F. Resident's medications were kept locked in med carts. Smoke detectors are interconnected with the sprinkler system. Carbon monoxide detector observed. First-aid kit was complete. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 3/19/24 at 1:00 PM, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Josephine Davis, Administrator and explained the purpose of the visit. The facility’s fire clearance was approved for 160. LPA toured the facility including but not limited to residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 70 degrees F. The hot water temperature in a residents’ bathroom was measured at 116.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 3/07/24. Emergency Disaster Plan was last posted on 10/02/23. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 2/27/24. LPA reviewed 5 residents records and 5 staff records, and all were complete. LPA also reviewed a sample of resident’s medications. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 1/04/24 at 12:30 PM, Licensing Program Analyst (LPA) Greg Clark conducted a Health & Safety inspection as a result of notice received from Attorney General Bonta that he had approved a conditional change in the control and governance of this facility from Elder Care Alliance to Transforming Age. LPA met with Administrator, Josephine Davis and explained the purpose of the visit. Due to the facility being in an active COVID out break status LPA was unable to tour the facility or speak to residents. LPA interviewed S1 during the visit. S1 reported that on 12/15/23 a public meeting was held at the facility to discuss the change of control and governance of the facility. In attendance were: residents and family members, facility staff, the CEO's of both Elder Care Alliance and Transforming Age and the Assistant Attorney General of the State of California. The meeting lasted approximately 1.5 hours. S1 further reported that there have been no changes at the facility. All staff and residents remain stable and there is no plans, at this point, to change any of the residents' contract to reflect the change of control and governance. The old contracts will remain in place. No issues identified at this time. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 7/25/23 at 1:35 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to continue the 1-Year Annual Required inspection started on 3/16/23. LPA met with Asst. Executive Director, Josie Davis and explained the purpose of the visit. During the visit LPA interviewed 5 staff, inspected the medication room, medication cart and reviewed a sample of 3 resident's medications. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

***report continuesfrom LIC9099** Staff did not dispense medication assistance to clients in care LPA reviewed MARs from April, May and June 2022. LPA observed that all medications we signed off as dispensed by the med techs. Facility uses an electronic MAR system. Facility did not report medication errors LPA reviewed written warning records dated 4/27/22 for med techs documented medication administration errors. LPA also reviewed physician communication form dated 5/02/22 that documents that the medication errors would not cause harm to the resident in care. Facility staff did not report the medication error to CCL as the error did not threaten the welfare, safety or health of the resident. Facility staff were re-trained on proper medication administration procedures on 4/29/22. Facility did not conduct a reappraisal of resident’s care needs LPA reviewed the facility file for R1. R1 lives in the assisted living section of the building. R1’s family provides R1 with a 1:1 aide. R1 is currently on hospice. LPA observed that physician’s reports for R1 were completed on 4/19/19, 5/20/21 and 9/10/23. R1’s primary diagnosis is documented as Parkinsons. R1 is not diagnosed with dementia. This agency has investigated the allegations that staff did not dispense medication assistance to clients in care, facility did not report medication errors and facility did not conduct a reappraisal of resident’s care needs. Based on LPA's observations, record review and interviews which were conducted the allegations were found to be unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.

On 3/3/26, around 945am, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to amend the Complaint Investigation Report dated 01/05/2016 and to obtain the Administrator's signature on the amended report. LPA met with administrator Kathleen McCarron and explained to the administrator why the amendment. LPA amended the report, and after a short discussion about the amendment, the administrator signed the amended report. No citation during this visit. An exit interview was conducted, and a copy of this report was provided.