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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202746
Report Date: 09/09/2023
Date Signed: 09/15/2023 04:03:36 PM


Document Has Been Signed on 09/15/2023 04:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA



FACILITY NAME:DEL MONTE MEMORY CARE FACILITYFACILITY NUMBER:
275202746
ADMINISTRATOR:ERNEST GIBSONFACILITY TYPE:
740
ADDRESS:1221 DAVID AVETELEPHONE:
(831) 375-2206
CITY:PACIFIC GROVESTATE: CAZIP CODE:
93950
CAPACITY:6CENSUS: 3DATE:
09/09/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Kay CabucoTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced visit to the facility September 9, 2023, at 9:30am. for a Case Management - Health Checks visit. LPA met with facility Executive Director Kay Cabuco and explained the purpose of the visit.

LPA Monter toured the facility in part to include lobby, kitchen, courtyard area, resident bedrooms, bathrooms and common areas. LPA toured the locked facility medication area and reviewed 1 resident medication records. LPA observed 1 staff member attending to the memory care residents. LPA observed perishable food supplies and non perishable food suply.

LPA asked staff member (S1) his/her name. LPA checked LIS facility summary report and guardian. Staff S1 is associated with Del Monte assisted living facility. S1 is not associated with Del Monte Memory care facility. LPA asked ADM if S1 was associated. ADM was not associated at the memory care facility. ADM stated they would associate S1 today.

ADM stated she sent request to change facility ADM to CCl office on August 21st 2023. ADM stated 3 caregivers for AL, 1 for memory care each shift.

A deficiency is being cited per California Code of Regulations, Title 22. A civil penalty is being assessed for the amount of $100 ($100 per day x 1 day = $100) for staff (S1) working at the facility without clearance transfer. Please LIC421BG

This report was reviewed with ADM Cabuco and a copy of the report and appeal rights were provided.
This report was written manually and provided to ADM on 09/09/2023. This copy was transcribed to FAS.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 712-2018
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 09/15/2023 04:03 PM - 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
Lookup Error,
, CA


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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/09/2023
Section Cited
CCR
87355(e)(2)

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87355(e)(2)All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b)shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) ... This requirement is not met as evidenced by:
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Licenseee will associate S1 to the facility, And send letter of understanding regarding regulation.
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Based on record review, and interview the licensee did not ensure staff (S1) was associated to the facility prior to working in the memory care facility which poses an immediate health, safety, and personal rights risk to persons 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: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 712-2018
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2