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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 275202747
Report Date: 04/09/2022
Date Signed: 04/22/2022 11:44:50 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/22/2021 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20210422134144
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: 49DATE:
04/09/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Audrey LigginsTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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 Insufficient staff to respond to resident call signal system.
Staff not following doctor orders
Facility failed to maintain supplies for diabetic residents needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced complaint investigation on this day.

Allegation: Insufficient staff to respond to resident call signal system. LPA reviewed interviews with staff and Administrator which was conducted on multiple occasions. During these interviews all interviewed denied having any issues with the call system or response times for the residents. LPA Johnson reviewed call system log and confirmed that the response time varies however, the times do not exceed a reasonable amount of time.

Allegation: Staff not following doctor orders. LPA reviewed the Physician's report (LIC 602) and confirmed that the facility is following Physician's order for a regular diet. R1 moved from the facility on 1/26/2022.

Continued>>
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2022
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 2
Control Number 26-AS-20210422134144
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: DEL MONTE ASSISTED LIVING FACILITY, THE
FACILITY NUMBER: 275202747
VISIT DATE: 04/09/2022
NARRATIVE
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Allegation: Facility failed to maintain supplies for diabetic residents needs. During the medication review for R2, LPA observed separate diabetic supplies for three of three residents in care. LPA was unable to corroborated the time period prior to the investigation date and as a result finds the allegation to be unsubstantiated.

The Department has investigated the above mentioned allegations and has determined that the complaint is UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur, therefore the allegation is unsubstantiated.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2