275202747-3-4-2022-24-AS-MHON-CDUTNT-20220426145317

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 275202747
Report Date: 03/04/2022
Date Signed: 03/04/2022 03:04:09 PM

Unfounded

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
02/25/2022 and conducted by Evaluator Melinda Medina

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20220225135913

FACILITY NAME:	DEL MONTE ASSISTED LIVING FACILITY, THE		FACILITY NUMBER:	275202747
ADMINISTRATOR:	SANDEEP SAINI		FACILITY TYPE:	740
ADDRESS:	1229 DAVID AVE		TELEPHONE:	(831) 375-2206
CITY:	PACIFIC GROVE	STATE: CA	ZIP CODE:	93950
CAPACITY:	49	CENSUS:	DATE:	03/04/2022
		UNANNOUNCED	TIME BEGAN:	11:35 AM
MET WITH:	Lakeisha James Gloria Kumer		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff did not supervise resident resulting in multiple falls and injuries
Facility does not have a signal system in place

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) M. Medina arrived to facility to conduct a 10-day initial complaint visit. LPA identified herself and discussed the purpose of the visit. Facility tour conducted with Lakeisha James, Consultant and Gloria Kumer, Med Technician.

Upon review of resident (R1) records, LPA found physician report does not indicate that R1 requires one on one supervision or that R1 requires assistance with self-care needs including toileting. During tour of facility, LPA observed telephones in each resident room. LPA observed when telephone receiver is picked up, it calls the caregiver telephone who is working in the building to indicate resident requires assistance.
These allegations are unfounded.

An exit interview was conducted with Lakeisha James, signed on site and a copy of this report will be provided via e-mail.

No deficiencies cited.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Melinda Medina	TELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022

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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