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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202747
Report Date: 02/23/2021
Date Signed: 03/01/2021 10:34:43 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:DEL MONTE ASSISTED LIVING FACILITY, THEFACILITY NUMBER:
275202747
ADMINISTRATOR:GALEANO, JULIAFACILITY TYPE:
740
ADDRESS:1229 DAVID AVETELEPHONE:
(831) 375-2206
CITY:PACIFIC GROVESTATE: CAZIP CODE:
93950
CAPACITY:49CENSUS: 38DATE:
02/23/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Julia GaleanoTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted a Technical Assist (TA) Visit via FaceTime with Julia Galeano Administrator and Barbie Henson Health Facilities Evaluator Nurse (HFEN) California Department of Public Health. The purpose of the visit was to provide technical assistance for Infection Prevention and Control guidelines for Adult and Senior Care facilities. LPA conducted a virtual tour of the facility.

The following recommendations were discussed:

1. Post Do Not Enter Without Full PPE signage outside isolation room(s).
2. Post PPE Donning (outside) and Doffing (inside ) signage for isolation room(s).
3. Maintain Hand Washing signage by bathroom sinks.
4. Rearrange furniture and or place tape across to maintain social distancing practices.
5. Post signage in the elevator to limit the number of occupants to two at a time.

Report reviewed with Julia Galeano and copy emailed for signature purposes.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE:
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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