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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 275202746
Report Date: 02/06/2023
Date Signed: 03/02/2023 04:50:42 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
12/28/2021 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 26-AS-20211228115517
FACILITY NAME:DEL MONTE MEMORY CARE FACILITYFACILITY NUMBER:
275202746
ADMINISTRATOR:SANDEEP SAINIFACILITY TYPE:
740
ADDRESS:1221 DAVID AVETELEPHONE:
(831) 375-2206
CITY:PACIFIC GROVESTATE: CAZIP CODE:
93950
CAPACITY:6CENSUS: 0DATE:
02/06/2023
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administrator, Robbie Cantiori TIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff burned resident's arm
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on the above allegations. LPA Hurt met with facility Administrator, Robbie Cantiori and explained the purpose of today's visit.
Regarding the allegation Staff burned resident's arm. Based on interviews conducted by Department of Social Services through the course of this investigation staff did not burn resident’s arm. During interviews Resident 1 denied anyone at the facility tried to hurt her and stated the wound on her arm was from a fall. Reporting Party stated she never said the marks on Resident 1’s arms were “cigarette burns” and only used that wording to describe Resident 1’s arm. This agency has investigated the complaint alleging staff burned residents arm. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

No deficiencies are being cited Per Title 22 Regulations. Exit Interview Conducted with Administrator Robbie Cantiori. A copy of this report along with appeals rights provided


Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023
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 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
12/28/2021 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 26-AS-20211228115517

FACILITY NAME:DEL MONTE MEMORY CARE FACILITYFACILITY NUMBER:
275202746
ADMINISTRATOR:SANDEEP SAINIFACILITY TYPE:
740
ADDRESS:1221 DAVID AVETELEPHONE:
(831) 375-2206
CITY:PACIFIC GROVESTATE: CAZIP CODE:
93950
CAPACITY:6CENSUS: 0DATE:
02/06/2023
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administrator, Robbie Cantiori TIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility staff did not follow resident's doctor's orders
Staff did not accurately maintain resident's medication records
Facility did not maintain a visitor COVID-19 screening area
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on the above allegations. LPA Hurt met with facility Administrator, Robbie Cantiori and explained the purpose of today's visit.
Regarding the allegation Facility staff did not follow resident's doctor's orders. Reporting party stated they had gone to the facility on 12/27/2021 because on 12/22/2021, she heard that Resident 1 had symptoms of a urinary tract infection (UTI). Reporting party stated they called the facility on 12/23/2021 to request an order be submitted to collect a specimen to determine if Resident 1 did have a Urinary Tract Infection. Reporting Party sent a photograph of the physician’s order for Urinalysis testing dated 12/23/2021. Reporting Party stated 4 days later 12/27/2021 no urine sample had been collected. LPA reviewed records documenting a Urinalysis order on 12/23/2021, and another on 12/27/2021. It was determined through Urinalysis collected Resident 1 did have a Urinary Tract Infection. Based on interviews which were conducted and facility records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.



Continued on 9099C...
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: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 26-AS-20211228115517
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: DEL MONTE MEMORY CARE FACILITY
FACILITY NUMBER: 275202746
VISIT DATE: 02/06/2023
NARRATIVE
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..Continued from 9099

Regarding the allegation Staff did not accurately maintain resident's medication records. Reporting party stated he stated the staff told her the December medication log was not ready yet. Reporting party stated they were given the November medication log, and the log had entries for Resident 1 on dates when she was out of the facility and in a skilled nursing facility. She said the staff told her the dates on the log were circled to show that Venus was absent from the facility, but she was not sure. Reporting Party stated she was given the December log, and the log was empty for dates 12/1/2021 through 12/31/2021. Reporting Party stated staff Licensee Anu assured her that the medications were given on those dates, but they were not logged. LPA Hurt reviewed MAR for Resident 1 dated 12/13/2021 – 12/31/2021 are blank with no signature despite Resident 1 being at the facility on these dates. Based on interviews which were conducted and facility records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.




Regarding the allegation Facility did not maintain a visitor COVID-19 screening area. Based on previous Licensing staff observations during several facility visits the facility does not maintain a COVID 19 screening area. Therefore, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. The facility has been previously cited on 03/12/2022 for not properly screening for COVID 19 symptoms at facility entrance, and no further citations will be issued at this time.

The following deficiencies are being cited Per Title 22 Regulations.

Exit interview conducted with facility Administrator, Robbie Cantiori, and copy of report provided.

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 26-AS-20211228115517
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: DEL MONTE MEMORY CARE FACILITY
FACILITY NUMBER: 275202746
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/07/2023
Section Cited
CCR
87465(a)
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87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. The following requirement has not been met as evidenced by:

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The Licensee will provide staff training on timely medical care and provide proof to LPA by POC date 02/07/2023.
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The Licensee did not provide Resident 1 with timely medical care for a UTI which poses an immediate, health, safety, or personal rights risk to residents in care.
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Type B
02/21/2023
Section Cited
CCR
87465(6)
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87465 Incidental Medical and Dental Care.
(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:The following requirement has not been met as evidenced by:
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The Licensee will conduct Medication Administration training with facility staff, and submit proof to LPA by POC date of 02/21/2023.
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The Licensee did not correctly document medications for Resident 1 several days in the month of December 2022 which poses a potential health, safety, or personal rigths risk to 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: 02/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
12/28/2021 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 26-AS-20211228115517

FACILITY NAME:DEL MONTE MEMORY CARE FACILITYFACILITY NUMBER:
275202746
ADMINISTRATOR:SANDEEP SAINIFACILITY TYPE:
740
ADDRESS:1221 DAVID AVETELEPHONE:
(831) 375-2206
CITY:PACIFIC GROVESTATE: CAZIP CODE:
93950
CAPACITY:6CENSUS: 0DATE:
02/06/2023
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administrator, Robbie Cantiori TIME COMPLETED:
03:45 PM
ALLEGATION(S):
1
2
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Staff applied improper bandaging to resident
Facility observed without staff present
Facility did not notify resident's responsible party of injuries
Resident left unsupervised during doctor's appointment
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on the above allegations. LPA Hurt met with facility Administrator, Robbie Cantiori and explained the purpose of today's visit.
Regarding the allegation Staff applied improper bandaging to resident. Based on interviews, and records reviewed the facility staff did not apply improper bandage to resident’s arm. Reporting Party stated that on 12/27/2021 they visited Resident 1 and observed their arm to be in a bandage. Reporting Party described the bandage on Resident 1’s arm as adhesive. Reporting Party stated she was told by Facility Staff 2, Resident 1 had an arm injury, and the adhesive bandage may tear the skin off if removed. LPA Hurt reviewed medical records from the month of 12/2021 and did not see anything documenting a specific type of bandage to be used on Resident 1’s arm wound. The Reporting Party’s observation and statement is the only reason the bandage was deemed to be improper. Therefore, this allegation is UNSUBSTANTIATED. A finding that an allegation is unsubstantiated means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.
Continued on 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 26-AS-20211228115517
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: DEL MONTE MEMORY CARE FACILITY
FACILITY NUMBER: 275202746
VISIT DATE: 02/06/2023
NARRATIVE
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..Continued from 9099


Regarding the allegation Facility observed without staff present. On 12/29/2021 Law enforcement conducted a welfare check to the facility, and observed three to four employee's present in the memory care area. LPA Hurt has conducted several visits to the memory care area of the facility and observes several staff members during each visit. Based on observation this allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation Facility did not notify resident's responsible party of injuries. Based on interviews conducted, and records reviewed the facility did notify Responsible party of injuries. Responsible Party for Resident 1 stated she was not notified of a wound on Resident 1’s arm that was discovered by staff on 12/25/2021 until 12/27/2021. LPA Hurt reviewed Unusual Incident/ Injury Reported dated 12/27/2021 documenting Staff 1 went to give Resident 1 medications and noticed they had a bandage over their arm. Staff 1 asked Resident 1 “what happened?” and Resident 1 stated “she wasn’t sure” The Incident Report documents Responsible Party was informed. It is unclear when the facility staff discovered the wound on Resident 1’s arm as the only documentation is dated 12/27/2021. Therefore, this allegation is UNSUBSTANTIATED. A finding that an allegation is unsubstantiated means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.


Regarding the allegation Resident left unsupervised during doctor's appointment. Based on interviews conducted the reporting party stated she met Resident 1 at a medical appointment on 09/27/2021 and observed them waiting in the lobby area. Reporting party stated she was told by the facility they were short staffed and agreed to hire outside transportation to take Resident 1 to the medical appointment. Reporting party was present at the facility when Resident 1 was loaded into the transportation van to be taken to the medical appointment. Reporting party stated upon their arrival to the appointment Resident 1 was inside the building waiting for them. Although the facility did agree to transport Resident 1 to the medical appointment it is unclear the arrangement between Reporting Party and the facility about the details of who would attend the medical appointment with Resident 1. Therefore, this allegation is UNSUBSTANTIATED. A finding that an allegation is unsubstantiated means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No Deficiencies Cited today Per Title 22 Regulations. Exit Interview conducted with facility Administrator Robbie Cantiori, and a copy of this report along with appeals rights provided.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7