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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 275202746
Report Date: 09/13/2023
Date Signed: 10/09/2023 08:42:54 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 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
07/21/2023 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 24-AS-20230721164703
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:
09/13/2023
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Facility Administrator, Kay CabucoTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility does not have sufficient staff to meet resident needs
INVESTIGATION FINDINGS:
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On 09/13/2023, Licensing Program Analyst(LPA) Sarah Hurt arrived at the facility unannounced to conduct a complaint investigation. LPA met with Facility Administrator, Kay Cabuco announced the purpose of the inspection.

Regarding the allegation Facility does not have sufficient staff to meet resident needs. LPA Hurt interviewed three facility caregivers. Two of the three caregivers stated the facility is short staffed, and more caregivers are needed especially on overnight shifts. Staff 1 stated there was recently an overnight shift where one staff was responsible for the residents in Assisted Living, and Memory care. Based on the interviews and the information received during this investigation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be substantiated at this time.

The following Deficiencies are being cited Per Title Regulations.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 24-AS-20230721164703
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: DEL MONTE MEMORY CARE FACILITY
FACILITY NUMBER: 275202746
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/27/2023
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement was not met as evidenced by:
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The facility Administrator has agreed to increase staffing and competency in order to meet the needs of the residents. CCLD will continue to monitor the facility.
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Based on interviews and records review, staff were not sufficient in numbers to properly meet the needs of the residents, which poses a potential risk to health, safety, and personal rights of the 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: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2