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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202746
Report Date: 09/10/2023
Date Signed: 09/15/2023 04:05:52 PM


Document Has Been Signed on 09/15/2023 04:05 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:
09/10/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator Kay CabucoTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced visit to the facility September 10, 2023 at 9:45am. for a Case Management - Health Checks visit. LPA met with facility Administrator (ADM) Kay Cabuco and explained the purpose of the visit.

LPA Monter toured the facility inside and out to include; resident bedrooms, kitchen, laundry area. LPA toured the medication area as well. LPA observed staff S1 in the home supervising residents who were watching television. LPA observed sufficient perishable and nonperishable food supply. LPA discussed with ADM the importance of having her staff fingerprinted and associated, ADM agreed and understood. LPA asked ADM who covers for Memory Care staff if they need to go to lunch or use the restroom. ADM stated they use an app to communicate with other staff if they need assistance with covering for lunch, breaks, bathroom, etc. ADM stated the other staff are associated with the home as well. ADM stated she can also cover if needed.

LPA discussed with ADM that he/she needs to be at each facility at least 20 hours each. ADM agreed and understood ADM provided LPA with LIC500 and staff schedule.

No deficiencies Cited today Per Title 22 Regulations. Exit Interview Conducted with Administrator Kay Cabuco, and a copy of this report was provided.

This report was written manually and provided to ADM on 09/10/2023. 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: 09/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2023
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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