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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 275202407
Report Date: 06/23/2023
Date Signed: 06/23/2023 04:17:53 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/16/2023 and conducted by Evaluator Brianna Miranda
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20230316145640
FACILITY NAME:MONTEREY BAY GUEST HOMEFACILITY NUMBER:
275202407
ADMINISTRATOR:EMMANUEL & JENNIFER INNEHFACILITY TYPE:
735
ADDRESS:1100 CARSON STREETTELEPHONE:
(831) 920-1796
CITY:SEASIDESTATE: CAZIP CODE:
93955
CAPACITY:22CENSUS: 19DATE:
06/23/2023
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Caregiver- Larry RimasTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff are not clearly noting dispensed medication in MAR's
INVESTIGATION FINDINGS:
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On 6/23/23 at 4:00 p.m. Licensing Program Analyst (LPA) B. Miranda arrived to the facility unannounced to deliver the finding of the allegations listed above. LPA was greeted by staff and allowed entry into the facility. LPA requested Administrator (AD) be contacted, AD authorized caregiver Larry Rimas to sign.

1. The Department investigated the allegation: Staff are not clearly noting dispensed medication in MAR's LPA interviewed 3 residents and 2 staff members. LPA originally arrived on 3/23/23 at 12:08 p.m. and obtained a copy of the MARs for March. LPA observed 2 resident's MARs which did not indicate the 7:00 a.m. or 8:00 a.m. medications were distributed. LPA asked S1 if medication had been given this morning and S1 stated medication had been given already.

Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 & Chapter 1, are being cited on the attached LIC 9099D
Exit interview was completed and a copy of LIC9099 report was provided to AD.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Brianna Miranda
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 24-AS-20230316145640
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: MONTEREY BAY GUEST HOME
FACILITY NUMBER: 275202407
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2023
Section Cited
CCR
80070
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(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.
This requirement is not met as evidenced by:
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Caregiver will speak with Administrator and have POC submitted by due date
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Based on LPAs observations, interview, and record reviews, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Facility uses MARs to keep records of medications given daily. S1 caregiver stated the medication had already been given when LPA asked about the morning medications.
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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: Brenda Chan
LICENSING EVALUATOR NAME: Brianna Miranda
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2