275202746-4-8-2022-26-AS-KHOS-CF8MT2-20220609095249

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 275202746
Report Date: 04/08/2022
Date Signed: 04/08/2022 02:35:01 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/01/2021 and conducted by Evaluator Marybeth Donovan

COMPLAINT CONTROL NUMBER: 26-AS-20210401155857

FACILITY NAME:	DEL MONTE MEMORY CARE FACILITY		FACILITY NUMBER:	275202746
ADMINISTRATOR:	GALEANO, JULIA		FACILITY TYPE:	740
ADDRESS:	1221 DAVID AVE		TELEPHONE:	(831) 375-2206
CITY:	PACIFIC GROVE	STATE: CA	ZIP CODE:	93950
CAPACITY:	6	CENSUS: 6	DATE:	04/08/2022
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Loria Garrison		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility does not have Fire clearance for locked exterior gate

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Marybeth Donovan arrived unannounced to deliver the complaint investigation finding. LPA met with Loria Garrison Med Tech and explained the purpose of the visit. LPA toured the facility inside and out.

Administrator and 3 staff confirmed the entry gate to memory care had been changed from the original configuration approved by the Fire Department. LPA observed the entry gate was locked from the inside. Staff restored the lock system to the original configuration during visit on 4/6/2021 and LPA confirmed this during today's visit.

Records review did not contain Fire Department approval and this was confirmed with Fire Department representative.

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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

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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Control Number 26-AS-20210401155857

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: DEL MONTE MEMORY CARE FACILITY	FACILITY NUMBER: 275202746
	VISIT DATE: 04/08/2022

NARRATIVE

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The Department investigation the above complain allegation. Based on interviews, records review and observation, there is preponderance of evidence to prove the alleged violation did occur, therefore the allegation is SUBSTANTIATED.

See 9099-D for deficiencies cited per the California Code of Regulations, Title 22.

Report reviewed with Loria Garrison and a copy of this report and appeal rights provided.

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SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20210401155857

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: DEL MONTE MEMORY CARE FACILITY	FACILITY NUMBER: 275202746
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/08/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/11/2022 Section Cited CCR 87705(I)(2)	1 2 3 4 5 6 7	87705 Care of Persons with Dementia (l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates.	1 2 3 4 5 6 7	Licensee/Administrator had the gate lock removed during visit. Licensee/Administrator will review Regulation 87705 sections (H)-(I) and submit a statement of understanding regarding these Regulations and submit by POC date.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on interviews, records review and observation, the facility did not obtain Fire Department approval to lock exterior entry gate from inside. LPA observed locked gate on 4/5/2022 which poses an immediate risk to Health and Safety of residents in care. This gate lock was removed at time of visit.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

LIC9099 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/01/2021 and conducted by Evaluator Marybeth Donovan

COMPLAINT CONTROL NUMBER: 26-AS-20210401155857

FACILITY NAME:	DEL MONTE MEMORY CARE FACILITY		FACILITY NUMBER:	275202746
ADMINISTRATOR:	GALEANO, JULIA		FACILITY TYPE:	740
ADDRESS:	1221 DAVID AVE		TELEPHONE:	(831) 375-2206
CITY:	PACIFIC GROVE	STATE: CA	ZIP CODE:	93950
CAPACITY:	6	CENSUS: 6	DATE:	04/08/2022
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Loria Garrison		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility does not have sufficient staffing to meet the residents needs
Facility staff do not have training in dementia care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Marybeth Donovan arrived unannounced to deliver the complaint investigation findings. LPA met with Loria Garrison and explained the purpose of the visit. LPA toured the facility inside and out.

Administrator and 6 of 9 staff stated that there is sufficient staff to meet the residents needs. S1 stated that additional staff can respond if needed via their walkie talkie system. Back up staff from adjoining community available to assist. S3 stated that there is 1 staff scheduled per each shift. S3 stated that staff check on residents every 2 hours and 45 minutes if they have toileting or incontinence needs.

2 of 6 residents stated staff take care of their needs and they did not have any complaints. The other residents were not able to respond to interview questions.

Staff scheduled reviewed for 3/1/2021 through 4/30/2021 noted coverage during each shift AM, PM, NOC.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 26-AS-20210401155857

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: DEL MONTE MEMORY CARE FACILITY	FACILITY NUMBER: 275202746
	VISIT DATE: 04/08/2022

NARRATIVE

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Administrator and 6 of 9 staff stated they have training in Dementia Care and Care of the Elderly. 2 of 9 did not get involved with direct care.

7 staff training records reviewed for the period of 8/1/2020 through 4/1/2021 noted staff training included Dementia care and working with an aging population.

Based on information from interviews conducted with staff, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No Deficiencies cited under California Code of Regulations Title 22

Exit interview conducted with Loria Garrison Med Tech and a copy of this report provided.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

LIC9099 (FAS) - (06/04)

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