<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 04:32:27 PM


Document Has Been Signed on 05/04/2022 04:32 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:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:18 PM
MET WITH:Activities Director, Michelle SpenceTIME COMPLETED:
05:04 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 to conduct an Annual Inspection- Infection Control. 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.

LPAs conducted a facility tour with AD. Facility appeared cleaned. Hand sanitizer was available to residents and visitors. Social distancing is maintained in the common and dining areas. Common bathrooms did have a trash cans with lid. Hand washing posters were observed by the bathroom sinks. Bedrooms were checked and beds are six feet apart. LPAs observed a strong odor of urine in multiple rooms of the facility.

LPAs checked residents’ locked medications. Food supply was checked, LPAs did not observe a 7 day supply of non-perishable foods. 2-day supply of perishable foods observed. Cleaning and PPE supplies were checked. Facility does not have an adequate supplies of required PPE. Staff records were reviewed for good health and infection control training. Facility staff was observed with mask on. Residents wear masks when away from the facility. Resident’s files have updated emergency contact information. Administrator certification is current.

During the inspection, AD and the medication technician stated that there are currently 8 residents receiving hospice care. Review of records revealed that the facility has hospice for 6 residents. Record reviews revealed that the 8 out of 8 hospice residents do not have a hospice care plan. LPAs observed that the facility has retained a resident with a prohibited health condition.
CONTINUED TO 809C
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 4


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
VISIT DATE: 05/04/2022
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
26
27
28
29
30
31
32
LPA is requesting the following documents be submitted to the Fresno CCL office by 05/18/2022: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond.

Deficiencies are being cited on the attached 809D in accordance with the California Code of Regulations, Title 22, Division 6.

Exit interview conducted and a Plan of Correction was reviewed and developed with AD. A copy of this report and appeal rights were discussed and provided to AD, Michelle Spence, whose signature on this form confirms receiving these documents.

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
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/04/2022 04:32 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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(26)
87555 General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above when it was observed by LPAs that the facility did not have a 7 day supply of non-perishable foods which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2022
Plan of Correction
1
2
3
4
Licensee agrees to submit documenation or pictures of foods purchased for the facility to meet the requirements of the section cited above to the Fresno CCL office by the POC due date.
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above when it was observed that the multiple rooms in the facility had a strong odor of urine which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2022
Plan of Correction
1
2
3
4
Licensee agrees to submit a written statement detailing how the facility will be cleaned to ensure that the facility is clean, safe, sanitarty and odor free to the Fresno CCL office by the POC due date.

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 4


Document Has Been Signed on 05/04/2022 04:32 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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
87615(a)(1)
87615 Prohibited Health Conditions: (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interviews and record reviews, the licensee did not comply with the section cited above when facility staff disclosed that R1 has a prohibited health condition, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2022
Plan of Correction
1
2
3
4
Licensee agrees to submit a written statement detailing how the facility will meet the needs of the resident to the Fresno CCL office by the POC due date.
Request Denied
Type A
Section Cited
CCR
87633(a)(4)
87633 Hospice Care of Terminally Ill Residents: (a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill…when all of the following conditions are met: (4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each terminally ill resident or prospective resident

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above when it was observed that 8 out of 8 residents receiving hospice care did not have a written hospice care plan which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2022
Plan of Correction
1
2
3
4
Licensee agrees to submit a written hospice care plan for 8 out of 8 residents to the Fresno CCL office by the POC due date.

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: 4 of 4