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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202746
Report Date: 07/12/2022
Date Signed: 07/12/2022 02:40:05 PM


Document Has Been Signed on 07/12/2022 02:40 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



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: 6DATE:
07/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Saini Sandeep and Staff Ashely RiderTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Shawna Doucette and Regional Manager Brenda White contacted the facility to commence a Case Management. LPA and RM were met by Staff Ashley Rider. LPA and RM toured the facility with Administrator Saini Sandeep and Staff Ashely Rider.

LPA and RM reviewed resident records.

An exit interview was conducted with Administrator Saini Sandeep and a copy of this report was provided.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2022
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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