Inspection Reports for The Hampshire – A Provincial Senior Living Community

An unannounced complaint investigation visit was conducted in response to a complaint received on 2025-05-14 regarding multiple allegations including unqualified staff providing care, inappropriate rent increases, delayed call button responses, and acceptance of residents not in the plan of operation.

The investigation found no preponderance of evidence to substantiate any of the allegations. Personnel records met requirements, the facility's plan of operation addressed resident care types, call response concerns were not supported by resident interviews, and an overcharge in rent was credited back to the resident. All allegations were determined to be unsubstantiated.

The complaint included allegations of unqualified staff providing care, inappropriate rent increases, delayed response to resident call buttons, and acceptance of residents not in the plan of operation. All allegations were investigated and found to be unsubstantiated.

An unannounced complaint investigation visit was conducted in response to an allegation that facility staff do not ensure residents are accorded the ability to receive personal phone calls.

The investigation found that the facility does have a landline phone and a cell phone that residents can use to contact family, and staff assist residents upon request. There was insufficient evidence to substantiate the allegation, and no deficiencies were cited.

The allegation that facility staff do not ensure residents can receive personal phone calls was unsubstantiated due to lack of preponderance of evidence.

An unannounced complaint investigation visit was conducted in response to an allegation that staff do not follow infection control requirements.

The investigation found that the facility is following infection control requirements. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The allegation that staff do not follow infection control requirements was investigated and found to be unsubstantiated.

The inspection was an unannounced required annual inspection conducted to evaluate the facility's compliance with licensing requirements.

The facility was found to be clean, in good repair, and compliant with safety and health standards including proper food storage, medication management, and resident room safety features. One deficiency was cited related to failure to obtain and evaluate a recent medical assessment prior to accepting a resident for care.

The visit was conducted as a follow-up on a previous complaint investigation and residents' interviews regarding staff not responding to residents' calls in a timely manner.

The inspection found that residents' calls were not answered for over 20 minutes and in some cases over an hour. Additionally, one resident's physician report had not been updated since 2018, posing potential health and safety risks.

The visit was complaint-related, following up on previous complaint investigation about staff not responding to residents' calls in a timely manner.

An unannounced Case Management visit was conducted to review facility operations, amend a previous deficiency report, request administrator certification, and update the facility hospice waiver.

The Licensing Program Analyst toured the facility, observed residents, and amended a deficiency report from 3/12/25. The facility currently has 20 residents receiving hospice services. Facility files were requested to be provided by 03/21/2025.

An unannounced complaint investigation was conducted following a complaint received on 2025-03-10 regarding failure to provide resident reappraisal upon change in condition.

The investigation found that resident R1 did not receive updated reappraisal documents after a change in level of care, substantiating the complaint. The facility was cited for failure to provide updated admission agreements and reappraisal documentation, posing potential health and safety risks.

Complaint was substantiated that facility staff did not provide resident reappraisal upon change in condition.

The inspection was an unannounced complaint investigation visit triggered by an allegation that staff do not ensure the insect issue is being properly addressed for residents in care.

The investigation found a substantiated cockroach infestation in a resident's room, posing an immediate health, safety, and personal rights risk. The facility was cited for failure to maintain a clean, safe, sanitary environment as required by regulations.

The complaint was substantiated based on observations, interviews, and record reviews. The allegation was that staff did not properly address an insect issue affecting residents.

The visit was an unannounced Case Management visit conducted by the Licensing Program Analyst to review compliance and address a Decision and Order excluding a staff member from the facility.

No deficiencies were observed or cited during the visit. The Licensing Program Analyst served a Decision and Order excluding a staff member from the facility and ensured the facility updated its personnel records accordingly.

The inspection was an unannounced required annual inspection conducted to evaluate compliance with licensing regulations.

The facility was generally clean, well-maintained, and compliant with emergency preparedness and resident care standards. However, two type-B deficiencies were cited related to expired medication storage and solid waste containers lacking tight-fitting covers in resident bathrooms.

An unannounced complaint investigation visit was conducted due to multiple allegations including lack of timely staff response to calls for assistance, missed medications, failure to follow residents' care plans, multiple resident falls due to neglect, and failure to provide authorized representatives with care plan copies.

All allegations were substantiated based on interviews, record reviews, and observations. Significant deficiencies included excessive wait times for staff assistance, missed medications, failure to follow care plans, multiple falls due to neglect, and failure to provide required documentation to residents' representatives.

The complaint investigation was substantiated. Allegations included untimely staff response to calls for assistance, missed medications, failure to follow care plans, multiple falls due to neglect, and failure to provide care plan copies to authorized representatives. Evidence met the preponderance of evidence standard for all allegations.

The inspection was an unannounced case management visit to conduct health checks and review an incident that occurred on 12/19/2023.

No deficiencies were cited during the inspection. The Licensing Program Analyst conducted a tour to ensure no immediate health or safety concerns were present.

The visit was an unannounced required annual inspection conducted by a Licensing Program Analyst to evaluate compliance with regulations at Pacifica Senior Living Merced.

The inspection found the facility generally maintained safety and emergency preparedness, but noted deficiencies including debris and dead bugs in common areas and resident bedrooms, lack of non-skid mats in one resident shower, unsecured cleaning chemicals in the memory care kitchen, and inadequate documentation of emergency drills.

An unannounced complaint investigation was conducted in response to allegations received on 2023-01-06 regarding staff response times to call bells, adequacy of food service, and notification of authorized representatives of incidents.

The investigation found that although call bell logs showed extended response times due to technical issues, staff generally responded within 5 minutes. Food service was adequate with meals sometimes reheated per resident request. The facility did not fail to notify authorized representatives as none were on record for the resident in question. All allegations were unsubstantiated or unfounded.

The complaint investigation was unsubstantiated. Allegations included untimely call bell response, inadequate food service, and failure to notify authorized representatives. The evidence did not support these allegations.

The inspection was a case management - deficiencies visit conducted to address observations made during a prior complaint inspection #24-AS-20230106152902.

The inspection found that signal system devices installed at bedside and in bathrooms of sampled Memory Care bedrooms were inoperable, and staff conducted 30-minute resident checks without using pagers to receive signal alerts, posing a potential health and safety risk.

This visit was conducted as a follow-up to a complaint inspection #24-AS-20230106152902. The deficiency cited was based on observations made during that complaint inspection.

Unannounced complaint investigation visit conducted in response to multiple allegations received on 12/15/2022 regarding expired foods, insect infestation, elevator maintenance, resident injury, staffing adequacy, refrigerator condition, and theft of resident funds.

The investigation substantiated allegations of expired foods and insect infestation in resident rooms. Other allegations including elevator maintenance, resident injury, staffing adequacy, refrigerator condition, and theft of resident funds were found to be unfounded or unsubstantiated based on observations, interviews, and records review.

The complaint investigation was substantiated for expired foods and insect infestation. Other allegations including elevator maintenance, resident injury, staffing adequacy, refrigerator condition, and theft of resident funds were found to be unfounded or unsubstantiated.

Unannounced Case Management visit to follow up on multiple Unusual Incident/Injury Reports involving residents, including medication administration concerns, wound care, health and safety, and a resident going absent without leave (AWOL).

The facility failed to provide adequate supervision resulting in a Memory Care resident (R4) going AWOL, posing an immediate risk to health and safety. Other incidents involved medication administration and wound care follow-ups. A civil penalty was cited due to the supervision deficiency.

The visit was complaint-related following multiple Unusual Incident/Injury Reports. The substantiation includes a confirmed incident of resident R4 going AWOL due to lack of supervision, confirmed by Merced Police Department and supported by R4's Physician’s Report indicating mild cognitive impairment and inability to leave unassisted.

The inspection was an unannounced Annual Required Inspection conducted to evaluate compliance with regulations, including follow-up on Special Incident Reports submitted earlier in the year.

Deficiencies were cited related to unsecured hazardous areas such as unlocked laundry and housekeeping rooms, and maintenance issues including clutter in hallways, dried tree branches in the parking lot, and strong urine odor in a memory care resident's room. Plans of correction were initiated during the visit for some deficiencies.

Licensing Program Analyst conducted a case management visit due to the unavailability of the Administrator and to follow up on a death report for a resident, requesting records to be submitted.

No deficiencies were cited during the visit. The Licensing Program Analyst will follow up once records and interviews have been conducted.

The inspection was an unannounced complaint investigation visit triggered by multiple allegations including a resident fall resulting in injury, unmet care needs, inadequate food service, pest issues, and delayed staff response to call buttons.

The investigation found some allegations unsubstantiated, such as unmet care needs, laundry, food service, and pest presence. However, the complaint that a resident was left on the floor for an extended period and staff did not respond timely to call buttons was substantiated, resulting in a deficiency citation.

The complaint investigation was triggered by allegations including a resident fall with injury, unmet care needs, inadequate food service, pest issues, and delayed staff response. The fall and delayed response allegations were substantiated, while others were unsubstantiated.

The visit was an unannounced complaint investigation conducted in response to allegations received on 2021-12-29 regarding resident care and facility conditions.

The investigation found no substantiated evidence supporting the allegations that bedridden residents were not turned every two hours, residents were not receiving timely assistance with incontinence needs, or that the facility had roaches. The facility does have monthly pest control service but occasional pests were noted.

The complaint investigation was unsubstantiated as there was insufficient evidence to prove the alleged violations occurred.

The visit was an unannounced complaint investigation triggered by allegations received on 01/07/2022 regarding staff behaviors posing risks to residents, residents sustaining falls, residents being left soiled for extended periods, and staff stealing residents' medications.

The investigation found no substantiated evidence to support the allegations. Medication counts and administration were reviewed with no errors found, and interviews and records indicated no concerns regarding residents being left soiled or staff misconduct. The allegations were deemed unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was unsubstantiated. Allegations included staff behaviors posing risks, residents sustaining falls, residents left soiled, and staff stealing medications. Interviews and record reviews did not confirm these allegations.

An unannounced complaint investigation visit was conducted in response to an allegation of inadequate staffing to meet residents' needs.

The investigation found the allegation of inadequate staffing to be unfounded. Despite a COVID-19 outbreak causing staffing challenges, the facility continued hiring and focused on resident care.

The complaint alleging inadequate staffing to meet residents' needs was investigated and found to be unfounded; the complaint was dismissed.

The inspection visit was conducted as an unannounced complaint investigation following a complaint received on 01/25/2022 alleging that the facility was not following COVID-19 protocol.

Based on interviews and records review, the allegations that the facility was not following COVID-19 protocol were found to be unsubstantiated. COVID precautionary measures were observed at the point of entry on the date of the visit and on 02/02/2022.

The complaint alleging that the facility was not following COVID-19 protocol was investigated and found to be unsubstantiated due to lack of preponderance of evidence.

An informal office meeting was held to discuss recently identified issues and concerns associated with the operation of the facility.

The meeting addressed multiple operational concerns including accountability of the licensee governing body, administrator qualifications and duties, personnel requirements and operations, basic services, incidental medical and dental care, personal rights, and maintenance and operation.

The visit was an unannounced Case Management follow-up to assess the administration of the facility, including review of prior incidents and compliance with reporting requirements.

The inspection found deficiencies related to a resident going absent without leave (AWOL) despite being unable to leave unassisted, and failure to notify the Department in writing of a new facility administrator, posing health, safety, and personal rights risks.

The inspection was an unannounced complaint investigation visit conducted in response to complaints alleging residents sustaining pressure injuries while in care and staff not keeping the facility free from odor.

The complaint alleging residents sustaining pressure injuries was found to be unfounded after review of relevant facility files and interviews. The complaint alleging staff do not keep the facility free from odor was unsubstantiated due to lack of preponderance of evidence despite an odor observed on a prior date.

The complaint investigation addressed two allegations: 1) Residents sustaining pressure injuries while in care, which was found to be unfounded; 2) Staff do not keep the facility free from odor, which was unsubstantiated. The investigation included interviews with Memory Care Director Tracy Seibert and review of facility records. The facility had a resident with stage 2 pressure injuries receiving appropriate care. Odor was noted on a prior date but was not substantiated during the visit.

The inspection was an unannounced complaint investigation visit triggered by multiple allegations including failure to communicate with resident's responsible party, unclean resident room, failure to follow physician orders, presence of pests, and medication administration issues.

The investigation substantiated that facility staff did not effectively communicate with the resident's responsible party and did not ensure the resident's room was clean. The allegation that staff did not follow physician orders was found to be unfounded. The allegations regarding pests and medication administration were unsubstantiated based on evidence and interviews.

The complaint investigation was substantiated for failure to communicate with the resident's responsible party and failure to maintain a clean resident room. The allegation that staff did not follow physician orders was unfounded. The allegations of pests and failure to ensure resident took medications were unsubstantiated.

An unannounced complaint investigation visit was conducted following a complaint received on 07/14/2021 regarding resident participation in pre-admission appraisal and resident sleeping in her chair.

The investigation substantiated that the resident did not participate in the development of the pre-admission appraisal and that the resident sleeps on her recliner at night due to not receiving appropriate assistance.

The complaint was substantiated based on interviews, observations, and records review. The allegations that the resident was not given the opportunity to participate in the pre-admission appraisal and that the resident was sleeping in her chair due to lack of assistance were both substantiated.

Licensing Program Analyst Lady Cabrera conducted a case management visit to offer technical assistance to the Licensee.

The analyst recommended that the facility should provide residents' personal belongings and immediate items such as dentures, glasses, hearing aids, medication list, and/or medications when residents are transported to the hospital.

An unannounced complaint investigation visit was conducted in response to allegations that staff were not answering call buttons in a timely manner.

The investigation found substantiated evidence that staff response times to call buttons were delayed, sometimes taking 30 to 45 minutes, due to short staffing and other duties. This posed an immediate health and safety risk to residents.

The complaint alleged that staff were not answering call buttons in a timely manner. The allegation was substantiated based on interviews and review of call button records showing delayed responses.

The inspection was an unannounced complaint investigation visit triggered by allegations including resident falls and medication administration issues.

The investigation found one allegation substantiated regarding failure to administer resident medication, resulting in a deficiency citation and a civil penalty. Another allegation about failure to send medication list to hospital was unsubstantiated, and the resident fall allegation was also unsubstantiated.

The complaint investigation was triggered by allegations that a resident fell multiple times while in care, staff did not administer resident's medication, and staff did not send the resident's medication list with her to the hospital. The fall allegation was found unsubstantiated, the medication administration allegation was substantiated, and the medication list allegation was unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-05-19 regarding allegations that the facility did not obtain a medical assessment signed by a physician prior to resident acceptance and did not maintain current resident records.

The investigation found that the resident's physician report was completed prior to admission and included all required health and care information. Based on the physician's report and resident assessment, the complaint was found to be unfounded and dismissed.

The complaint alleged that the facility failed to obtain a medical assessment signed by a physician prior to resident acceptance and failed to maintain current resident records. The complaint was investigated and found to be unfounded.

The visit was a subsequent Case Management visit to discuss information obtained from a prior visit on 05/05/2021 and to address an incident that occurred on 04/25/2021 involving a resident striking another resident.

The incident involved one resident striking another on the jaw, with staff intervening immediately and transporting the injured resident to the hospital for evaluation. Both residents are reported to be doing well, and no other incidents were reported. Technical advisory was provided for reassessment and care needs.

The visit was a subsequent Case Management visit to address an incident on 03/23/2021 where resident R1 went absent without leave (AWOL) from the facility.

The facility was found deficient for failing to provide required basic services, as evidenced by the incident where resident R1, who has dementia and was unable to leave unassisted, went AWOL, presenting an immediate risk to health, safety, and personal rights of clients.

The visit was conducted as a subsequent Case Management visit to address incidents on 03/23/2021 and 05/16/2021 where a resident went absent without leave (AWOL), which was reported by facility staff.

The facility failed to meet the basic services requirement as resident R1, who was unable to leave unassisted per physician report, went AWOL twice, presenting an immediate risk to health and safety. A civil penalty of $500 was assessed as this was a second violation within twelve months.

The visit was an unannounced case management visit to address an incident that occurred on 03/21/2021, following up on the health and safety check of Resident 1 (R1).

Licensing Program Analysts conducted the visit and requested documents including the Most Physician Report 602, Reappraisal/Assessment, and Admission Agreement from the facility.

The visit was an unannounced case management visit to address incidents that occurred on 03/23/2021 and 05/16/2021, following up on the health and safety check of Resident 1 (R1).

Licensing Program Analysts conducted the visit and requested specific documents from the facility including the Most Physician Report 602, Reappraisal/Assessment, and Admission Agreement to follow up on the unusual incident reports submitted by facility staff.

Subsequent Case Management visit to discuss information obtained from the initial visit conducted on 04/23/2021, focusing on deficiencies related to medication administration.

The Licensee did not meet California Code of Regulations Title 22, Division 6, Chapter 8, Section 87465(c)(2) regarding Incidental Medical and Dental Care due to a medication error where a resident missed a prescribed dose. This is the third violation within twelve months, resulting in a civil penalty of $250.

The visit was a case management follow-up conducted by phone due to COVID-19 precautionary measures, to follow up on the health and safety check of two residents and to obtain additional information related to an Unusual Incident/Injury Report received on 04/30/2021.

The Licensing Program Analyst contacted the Memory Care Director by phone to request several documents including the Resident’s Admission Agreement, Physician's Report, Facility Narratives, and Staff contact information, which were to be submitted by 05/07/2021.

The visit was a case management follow-up conducted by phone due to COVID-19 precautionary measures, following receipt of an Unusual Incident/Injury Report to check on the health and safety of two residents and to obtain additional information.

The Licensing Program Analyst contacted the Memory Care Director by phone to discuss the incident and requested several documents including the Resident’s Admission Agreement, Physician's Report, Facility Narratives, and Staff contact information to be submitted by 5/7/2021.

The visit was a case management follow-up conducted by phone due to COVID-19 precautionary measures and to follow up on an Unusual Incident/Injury Report received on 03/18/2021, focusing on the health and safety check of a resident and obtaining additional information regarding the resident's change of condition.

The Licensing Program Analyst requested several documents including the resident’s admission agreement, physician's report and orders, facility assessments, medication lists, and staff contact information to be submitted by 4/27/2021. No deficiencies or violations were explicitly stated in the report.

The visit was a case management follow-up conducted by phone due to COVID-19 precautionary measures and to follow up on an unusual incident/injury report related to a medication error that occurred on 03/23/2021.

The Memory Care Director reported that staff involved in the medication error were immediately retrained. Licensing Program Analyst requested several documents related to the incident to be submitted by 04/27/2021.

The visit was a Case Management follow-up conducted to discuss information obtained from an initial visit on 03/04/2021, specifically regarding medication administration errors.

During the investigation, it was found that staff administered the wrong medication to a resident, resulting in a double dose. The resident was monitored with no adverse reactions. The licensee did not meet California Code of Regulations related to Incidental Medical and Dental Care, resulting in a cited deficiency and a civil penalty.

This was a complaint-related visit triggered by a medication error incident. It was the second violation within twelve months, with the first violation occurring on 11/17/2020. A civil penalty of $250.00 was assessed.

The inspection was an unannounced Case Management - Deficiencies visit conducted via telephone due to COVID-19 precautions, triggered by staff reports of Unusual Incident/Injury Reports submitted to the licensing agency.

The Licensee was found to have not met the California Code of Regulations regarding Personal Rights of Residents, specifically failing to ensure residents were free from punishment, humiliation, intimidation, abuse, or other actions interfering with daily living functions. The allegation was substantiated based on interviews and records review.

The complaint was substantiated based on the preponderance of evidence standard after review of staff statements and incident reports related to an event on 1/21/2020.

The visit was a case management incident follow-up conducted by phone to check on the health and safety of residents and to obtain additional information related to an unusual incident/injury report received by Community Care Licensing.

The Licensing Program Analyst contacted the facility administrator due to COVID-19 precautionary measures and requested several documents including the Resident’s Admission Agreement, LIC602A, staff contact information, and police report case number. An exit interview was conducted and a copy of the report was provided via email.

The inspection was an unannounced complaint investigation triggered by an allegation that staff were mismanaging residents' medications.

The investigation found the allegation substantiated based on records review and interviews. Medications had not been dispensed correctly according to physician directions, posing an immediate risk to residents.

The complaint was substantiated. The investigation was conducted via telephone due to COVID-19 precautions. The allegation involved mismanagement of residents' medications. The preponderance of evidence standard was met, confirming the allegation.