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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202746
Report Date: 03/12/2022
Date Signed: 03/14/2022 08:37:03 AM


Document Has Been Signed on 03/14/2022 08:37 AM - It Cannot Be Edited

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:
03/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Gloria KumerTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual inspection on 03/12/2022 at 8:00 AM. LPA met with Gloria Kumer and stated the purpose of today’s visit. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator holds current certificate # 6052138740 and expires on 05/07/2023. The facility is licensed for six non-ambulatory residents. There are currently 6 residents who reside at this facility. The facility has an approved hospice waver for two. There is resident on hospice.

LPA Martinez toured the facility with Christopher Aquino on 03/12/2022 at 9:00 AM.

The facility has one screening entry point at the facility's main office. During the annual, staff 1 entered the facility without being screened and not using a mask. The facility did have hand sanitizer. The furniture is spaced 6 feet apart. An immediate $500.00 dollar civil penalty will be assessed on today's date 03/12/2022 for not implementing Covid-19 precautionary measures, as S1 was not wearing a mask and was not screened before entering the facility.

It was learned all meals are prepared at the Del Monte Assisted Living Care Facility # 275202747. The Del Monte Assisted Living Care Facility is located next door to Del Monte Memory Care Facility. The two facilities share a pathway that connects the two separate properties. Additionally, the two facilities share one medication room, which is located at Del Monte Assisted Living Care Facility. The licensee did not follow the approved plan of operation for Del Monte Memory Care Facility, therefore the facility received a citation at today's visit. LPA Martinez requested that the licensee submit an update plan of operation to Community Care Licensing Department (CCLD). The updated plan of operation will include meal preparation and medication storage and administration procedures. In addition, CCLD will need to review updated plan of operation and approve it before any change can occur. Continued...

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2022
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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Document Has Been Signed on 03/14/2022 08:37 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA


FACILITY NAME: DEL MONTE MEMORY CARE FACILITY
FACILITY NUMBER: 275202746

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied: Appeal Not Submitted Timely
Type A
03/18/2022
Section Cited

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Health and Safety Code 1569.50(a)(3)
Conduct Inimical: Conduct which is inimical to health, morals, welfare or safety of either an individual in, or receiving services from the facility or the people of the State of California.

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based on observation the facility did not follow proper usage of face covering and did not implement COVID-19 pre-screening measures at entrance of facility. This poses an immediate health and safety risk to residents in care.
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Request Denied: Appeal Not Submitted Timely
Type B
04/01/2022
Section Cited

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80022(b)(7)(8) Plan of Operation: The plan and related materials shall contain the following: sketch of the building(s) to be occupied, including a floor plan which describes the capacities of the buildings for the uses intended...A sketch of the grounds showing...A sketch of the grounds showing buildings ...recreation areas and other space used by the clients.

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This requirement is not met as evidenced by: Based on observation and interviews, the facility sketch did not reflect the current layout of the facility. Facility garage is converted into a office and room 4 and room 6 share a bathroom. Room 4 closet was removed and now has a door to a bathroom This posed a potential health and safety risk to clients in care.
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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.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/14/2022 08:37 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA


FACILITY NAME: DEL MONTE MEMORY CARE FACILITY
FACILITY NUMBER: 275202746

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied: Appeal Not Submitted Timely
Type B
04/01/2022
Section Cited

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Personnel Requirements - General 87411(c)(1) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified...staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
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This requirement was not met as evidence by. Based on record review, 3 out 3 employee files did not have proof of a first aid certificate in their employee file. This posed a potential health and safety risk to residents in care.
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Request Denied: Appeal Not Submitted Timely
Type B
04/01/2022
Section Cited

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87705(5)(A) Care of Persons with Dementia Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
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This requirement was not met as evidence by. Based on record review: R3 did not have an updated reassessment. This posed a potential health and safety risk to residents.
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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.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/14/2022 08:37 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA


FACILITY NAME: DEL MONTE MEMORY CARE FACILITY
FACILITY NUMBER: 275202746

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied: Appeal Not Submitted Timely
Type B
04/01/2022
Section Cited

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87506(b)(15) Resident Records Each resident’s record shall contain at least the following information: The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.
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This requirement was not met as evidence by. Based on a file review R1 was missing updated admission agreement due to moving from AL facility to MC facility. This posed a potential health and safety risk to residents.
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Request Denied: Appeal Not Submitted Timely
Type B
04/01/2022
Section Cited

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87458(a)Medical Assessment Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year.
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This requirement was not met as evidence by. R1 was missing a new LIC 602 for transfer from AL facility to MC facility. R2 Did not have a LIC 602. LIC 602 present in file had no name it is unknown who the LIC 602 belongs to. This posed a potential health and safety risk to residents.
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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.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/14/2022 08:37 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA


FACILITY NAME: DEL MONTE MEMORY CARE FACILITY
FACILITY NUMBER: 275202746

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied: Appeal Not Submitted Timely
Type B
04/01/2022
Section Cited

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87458(b)(1) Medical Assessment The medical assessment shall include, but not be limited to:A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious diseases or other medical conditions which would preclude care of the person by the facility.
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This requirement was not met as evidenced by: Based on file reviews R1 did not have a current LIC 602 and previous LIC 602 had missing TB information. LIC 602 did not have an LIC 602. This posed a potential health and safety risk to residents in care.
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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.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2022
LIC809 (FAS) - (06/04)
Page: 5 of 10


Document Has Been Signed on 03/14/2022 08:37 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA


FACILITY NAME: DEL MONTE MEMORY CARE FACILITY
FACILITY NUMBER: 275202746

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied: Appeal Not Submitted Timely
Type B
04/01/2022
Section Cited

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87411 Personnel Requirements All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement was not met as evidenced by. Based on observation: 3 employee did not have annual training.
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Request Denied: Appeal Not Submitted Timely
Type B
03/25/2022
Section Cited

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87208(a)Plan of Operation Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval.
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This requirement was not met as evidence by: Based on observation the facility changed the MC facility plan of operation by making significant change how the facility is preparing meals and storing medications. Meals are prepared at AL facility and Medications are stored at AL facility this posed a potential health and safety risk to residents in care.
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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.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2022
LIC809 (FAS) - (06/04)
Page: 6 of 10


Document Has Been Signed on 03/14/2022 08:37 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA


FACILITY NAME: DEL MONTE MEMORY CARE FACILITY
FACILITY NUMBER: 275202746

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied: Appeal Not Submitted Timely
Type A
03/16/2022
Section Cited

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87705(l)(8) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates:
Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff.
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This requirement was not met as evidence by: based on interviews and file review. There were no fire drills conducted. This posed an immediate health and safety risk to residents in care.
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Request Denied: Appeal Not Submitted Timely
Type A
03/12/2022
Section Cited

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87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidence by:
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Based on observation resident room 1A did not have a working smoking detector. Resident room 5 was missing a smoke detector. This posed an immediate health and safety risk to residents in care.
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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.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2022
LIC809 (FAS) - (06/04)
Page: 7 of 10


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: DEL MONTE MEMORY CARE FACILITY
FACILITY NUMBER: 275202746
VISIT DATE: 03/12/2022
NARRATIVE
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It was learned the facility has not conducted fire drills. LPA interviewed two staff, and both reported not conducting fire drill. An immediate $500.00 dollar civil penalty will be assessed on today's date 03/12/2022 for not implementing fire drills. The facility fire extinguisher and carbon detector are up to date. Resident room one A smoke detector is not in good repair. Resident room five smoke detector is missing. An immediate $500.00 dollar civil penalty will be assessed on today's date 03/12/2022 for a missing smoke detector in room 5 and for a non-working smoke detector in room 1A.

The facility sketch does not reflect the sketch that was submitted to CCLD during the prelicensing process. The facility garage has been converted into an office. Additionally, Room 6 and Room 4 share a Jack and Jill bathroom. Room 6 exit door has been reconfigured to new part of the room . Room 4's closet has been removed and now has a door that connects to room's 6 bathroom.

LPA Martinez observed medication pass, and medications were not assessable to residents. Medications are in a locked room and stored in a locked medication cart. LPA reviewed Resident 2 Medication Administration Record (MAR). R2's MAR sheets were not completed and missing administration care staff signatures. LPA Martinez reviewed three employee files, and employee files were missing the following documents first aid, health screening, training, employee rights. LPA Martinez reviewed three resident files and the following documents were missing reassessments, Health Certification LIC 602, Reassessments, admission agreements, and Tuberculosis (TB) tests. Moreover, resident 1 (R1) was transferred from the AL facility to the MC facility. R1 did not have a new admission agreement for the MC facility and did not have a new LIC 602 form for the MC facility (Health Certification form). R1 was also missing TB information. Resident 2 (R2) did not have an LIC 602. There was an LIC 602 found in R2's file, however, there was no name on the LIC 602. LPA Martinez was not able to determine if the LIC 602 belonged to R2. Resident 3 (R3) did not have an annual reassessment for 2022 and missing TB information. R3's last assessment was on 03/02/2020 and last completed LIC 602 was on 02/25/2020.

Facility was sanitary and clean. The resident showers were missing non-slip mats. Resident bedroom Curtain rod is broken. The exterior of the facility has miscellaneous debris: old hospital bed, bed rails, old wood pieces. In addition, the facility gazebo is not in good repair. The facility has a two day and 7 day supply of food, however, it is located at Del Monte Assisted Living Care Facility. The facility has snacks available for residents. The facility has a public phone. There was an activities area, which included puzzles and coloring books. Staff 2 reported walking with residents around the facility. Continued...
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2022
LIC809 (FAS) - (06/04)
Page: 8 of 10
Document Has Been Signed on 03/14/2022 08:37 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA


FACILITY NAME: DEL MONTE MEMORY CARE FACILITY
FACILITY NUMBER: 275202746

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied: Appeal Not Submitted Timely
Type B
04/01/2022
Section Cited

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87303(a) Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by
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Based on observation the facility exterior has debris scattered throughout the back yard. Resident curtain rod is broken, and the bathrooms are missing non-slip mats.
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Request Denied: Appeal Not Submitted Timely
Type B
04/01/2022
Section Cited

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Incidental Medical and Dental Care 87465(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement was not met as evidence by: Based on observation and file review..
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the facility staff did not maintain R2 MAR sheet. this posed a potential health and safety risk to residents in care.
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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.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2022
LIC809 (FAS) - (06/04)
Page: 9 of 10


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: DEL MONTE MEMORY CARE FACILITY
FACILITY NUMBER: 275202746
VISIT DATE: 03/12/2022
NARRATIVE
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As a result of this visit, the following deficiencies were cited, per California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted, and a copy of the 809, 809D, and appeals right were given at the end of visit.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2022
LIC809 (FAS) - (06/04)
Page: 10 of 10