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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 11:39:51 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
12/10/2021 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20211210144122
FACILITY NAME:DEL MONTE ASSISTED LIVING FACILITY, THEFACILITY NUMBER:
275202747
ADMINISTRATOR:SANDEEP SAINIFACILITY 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:
03:00 PM
ALLEGATION(S):
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Staff are not following physicians order for a special diet
Residents files are not complete
Facility admitting residents prior to obtaining physician's report
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced complaint investigation on this day.

Allegation: Staff are not following physicians order for a special diet. LPA reviewed the Physician's report (LIC 602) and confirmed that the facility is following Physician's order for a regular diet. R1 moved into the facility on 1/9/2018, The doctors orders confirmed that there was no requirement for a special diet. There is a order for hydration monitoring and reminders, but not special requirements for modifying the consistency of the liquid. R1 moved from the facility on 1/26/2022. LPA reviewed the Medication Administration Records for November 2021.

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-20211210144122
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: Residents files are not complete. Based on records reviewed the facility has the required documents for 18 of 18 residents reviewed. The residents files for this time period were completed and in compliance. The reported time period for the allegation could not be confirmed.

Allegation: Facility admitting residents prior to obtaining physician's report. Based on records reviewed the facility had Physician's reports for 10 of 10 residents records reviewed. The facility has processes in place which includes a detailed check list of items that are required. The information in the reported allegation could not be corroborated.

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