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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202746
Report Date: 07/14/2021
Date Signed: 07/14/2021 03:53:57 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:DEL MONTE MEMORY CARE FACILITYFACILITY NUMBER:
275202746
ADMINISTRATOR:SANDEEP SAINIFACILITY TYPE:
740
ADDRESS:1221 DAVID AVETELEPHONE:
(831) 375-2206
CITY:PACIFIC GROVESTATE: CAZIP CODE:
93950
CAPACITY:6CENSUS: 6DATE:
07/14/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Sandeep Saini and Janet KumarTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Marybeth Donovan arrived unannounced to conduct a Case Management Visit regarding an elopement incident that occurred 03/18/2021. LPA met with Sandeep Saini Administrator and Janet Kumar, Executive Director.

Resident (R)1 was admitted to the memory care facility in March 2021. The front gate was alarmed and locked and operating properly. R1 is ambulatory.

Staff last saw R1 at 8:15pm. When staff went to check on R1, staff was unable to locate R1. Staff began search for R1. The Pacific Grove Police Department was notified and R1 was located and returned by the police at 9:15pm. No police report was created. R1 was not injured. Medical records indicate R1 is not able to leave the facility unassisted.

See attached LIC9102 Advisory Note regarding this elopement as resident exited the facility unsupervised.

No citations issued per the California Code of Regulations Title 22.

Report reviewed with Sandeep Saini Administrator and Janet Kumar Executive Director and a copy of this report and advisory note were provided.

SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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