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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 275202746
Report Date: 03/13/2022
Date Signed: 03/13/2022 09:05:51 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/22/2021 and conducted by Evaluator Avelina Martinez
COMPLAINT CONTROL NUMBER: 26-AS-20210422153111
FACILITY NAME:DEL MONTE MEMORY CARE FACILITYFACILITY NUMBER:
275202746
ADMINISTRATOR:GALEANO, JULIAFACILITY TYPE:
740
ADDRESS:1221 DAVID AVETELEPHONE:
(831) 375-2206
CITY:PACIFIC GROVESTATE: CAZIP CODE:
93950
CAPACITY:6CENSUS: 6DATE:
03/13/2022
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Loria GarrisonTIME COMPLETED:
09:15 AM
ALLEGATION(S):
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Physical plant altered
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 03/13/2022 at 8:00 AM to deliver complaint findings, LPA met with Loria Garrison and explained the purpose of the visit.

Throughout the course of the investigation, LPA Martinez conducted interviews and reviewed facility records. Complaint 26-AS-20210422153111 has been completed, and it was determined this allegation has been investigated during an annual inspection on 03/12/2022 and substantiated on that day. LPA Martinez reviewed the facility sketch that was submitted to Community Care Licensing Department (CCLD) and the sketch located inside of the facility. The sketches were different and there had been changes since the last submitted sketch to CCLD.

Continued...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2022
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 26-AS-20210422153111
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/13/2022
NARRATIVE
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LPA toured the facility with staff 1 (S1) on 03/12/2022. 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.

As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The deficiency cited can be found on the 809 Annual Report dated 03/12/2022. In addition, the plan of correction can be found on the 809 Annual Report dated 03/12/2022. As a result, no further citations will be given on today's visit.

Exit interview conducted was conducted, and a copy of the 809 report was given to the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2