275202746-8-1-2023-24-AS-BCHN-CVD7UB-20230904215800

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 275202746
Report Date: 07/27/2023
Date Signed: 08/01/2023 09:47:41 AM

Unsubstantiated

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
05/03/2023 and conducted by Evaluator David Ayers

COMPLAINT CONTROL NUMBER: 24-AS-20230503105432

FACILITY NAME:	DEL MONTE MEMORY CARE FACILITY		FACILITY NUMBER:	275202746
ADMINISTRATOR:	ERNEST GIBSON		FACILITY TYPE:	740
ADDRESS:	1221 DAVID AVE		TELEPHONE:	(831) 375-2206
CITY:	PACIFIC GROVE	STATE: CA	ZIP CODE:	93950
CAPACITY:	6	CENSUS: 3	DATE:	07/27/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Syed Majid - Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff do not provide proper medication assistance to residents in care
Staff do not provide proper food service to residents in care
Facility staff is not properly trained

INVESTIGATION FINDINGS:

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On 7/27/2023, Licensing Program Analyst (LPA) D. Ayers conducted an unannounced complaint inspection at 0900 hours. LPA met with admintrator Syed Majid. The purpose of this visit is to deliver the finding of the investigation completed by the Department.

LPA conducted a tour of the facility, interior and exterior to ensure there are no potential or immediate health and safety risk at the facility.

During the course of the investigation, the department inspected the facility, conducted interviews, and reviewed records. During review of the medication administration records, medications appeared to be administered properly. Facility staff were able to provide proof of necessary training required to administer medications. Meals appeared to be properly prepared and served to residents, and food appeared to be of adequate quality. Based on the interviews conducted, documentation obtained and reviewed, and the information received during this investigation, the preponderance of evidence standard has not been met; therefore, the above allegation is found to be unsubstantiated at this time. Exit interview conducted and a copy of the report was provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David Ayers	TELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

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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