<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202747
Report Date: 05/04/2022
Date Signed: 05/04/2022 04:26:01 PM


Document Has Been Signed on 05/04/2022 04:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



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: 43DATE:
05/04/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:Activities Director, Michelle SpenceTIME COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 05/04/2022, Licensing Program Analysts (LPAs) Walton and Doucette arrived unannounced for a Case Management - Deficiencies Inspection. LPAs introduced themselves, stated the purpose of the visit and requested to meet with the Administrator. LPAs were granted entry to the facility by Activities Director (AD), Michelle Spence. AD contacted Administrator, Saini Sandeep. Administrator is unable to attend this inspection. LPAs received verbal permission to meet with AD.

During the investigation of complaint #24-AS-20220324084737 the following deficiencies were observed:

On 03/25/2022, LPA arrived at the above facility to commence investigation. During the inspection, the Administrator was not available and the facility did not have a designated substitute with qualifications adequate to be responsible and accountable for management and administration of the facility. Facility was unable to provide staff files, as facility staff did not have a key to the staff file cabinet.

Record reviews revealed that staff S1 and S2 are not associated to the facility. LPA confirmed through LIS that staff are fingerprint cleared, but are not associated to the facility.
Deficiencies are being cited on the attached 809D in accordance with the California Code of Regulations, Title 22, Division 6. A civil penalty in the amount of $1000 is being issued for Caregiver Background Check.

Exit interview conducted and a Plan of Correction was reviewed and developed. A copy of this report and appeal rights were provided to Activities Director, Michelle Spence, whose signature on this form confirms receiving this document.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 05/04/2022 04:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: DEL MONTE ASSISTED LIVING FACILITY, THE
FACILITY NUMBER: 275202747

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/05/2022
Section Cited

1
2
3
4
5
6
7
(e) All individuals... prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)... This requirement was not met as evidenced by:
8
9
10
11
12
13
14
Based on record review, the licensee did not comply with the section cited when LPA observed that S1 and S2 are fingerprint cleared, but not associated to the facility, which posses an immediate health and safety risk to person in care
8
9
10
11
12
13
14
Type B
06/06/2022
Section Cited

1
2
3
4
5
6
7
87405 Administrator - Qualifications and Duties: (a) All facilities shall have a qualified and currently certified administrator...When the administrator is not in the facility, there shall be coverage by a designated substitute, this requirement was not met as evidenced by:
8
9
10
11
12
13
14
Based on observation, the facility did not comply with the section cited above when the Administrator was not present in the facility and did not have a designated substitue, this posses a potential health and safety risk to persons in care.
8
9
10
11
12
13
14
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: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 05/04/2022 04:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: DEL MONTE ASSISTED LIVING FACILITY, THE
FACILITY NUMBER: 275202747

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/06/2022
Section Cited

1
2
3
4
5
6
7
87412 Personnel Records: (f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours, this requirement was not met as evidenced by:
8
9
10
11
12
13
14
Based on observation, on 03/25/2022, personnel records were not available for LPA to audit during an inpsection. This poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3