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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202747
Report Date: 06/20/2022
Date Signed: 06/20/2022 06:30:55 PM


Document Has Been Signed on 06/20/2022 06:30 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: 48DATE:
06/20/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:54 PM
MET WITH:Staff Ashley RiderTIME COMPLETED:
06:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Shawna Doucette, Lady Cabrera and Licensing Program Manager Brenda Chan contacted the facility to commence a complaint investigation. During the course of the investigation additional deficiencies were observed and a case management was conducted. LPA contacted Administrator Saini Sandeep via telephone who advised Staff Ashley Rider could assist with the visit.

LPA's observed bleach on the kitchen counter in House #5 accessible to residents in care. LPA's observed cleaning supplies accessible in to residents in House #7 in the unlocked linen closet. LPA's observed a broken mirror outside of the maintenance shed accessible to residents in care.

Facility staff did not take Covid 19 precautionary measures prior to entry.

LPA's observed the toilet paper roll was left on sink and toilet paper roll was broken, outdoors near shed had trash, facility had old mattress and chairs outside on facility grounds, walkway has overgrown plants, and kitchen and resident rooms need to be cleaned.

Based on observations and interviews, facility does not have enough staff to enforce sign in and sign out policies. HR staff and Office staff are assisting with caregiver duties.

LPA's observed expired food in the kitchen refrigerator dating back to May 2022. LPA's observed molded cantaloupe which will be cited at a later date.

LPA's observed several doors blocked by items however will issue citation at a later date after facility sketch is reviewed. LPA's advised staff that any items blocking doors or exit hallways need to be removed.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/20/2022 06:30 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: 06/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/22/2022
Section Cited

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87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
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This requirement was not met as evidenced by Based on observation, Licensee did not lock up cleaning supplies in House #5 and House #7 and failed to secure a broken mirror outside of the maintenance shed which poses an immediate health, safety and/or personal rights risk to the residents in care.
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Type A
06/22/2022
Section Cited

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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement was not met as evidenced by
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Based on observation, Licensee did not repair toilet paper holder where toilet paper was left on sink, outdoor near shed had trash, facility had old mattress and chairs outside on facility grounds, walkway has overgrown plants, kitchen needs to be cleaned and residents rooms need to be cleaned which poses an immediate health, safety and/or personal rights risk to the residents in care.
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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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 06/20/2022 06:30 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: 06/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/22/2022
Section Cited

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87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
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Based on observation, Licensee did not comply with covid guidelines, has a lack of knowledge, and did not ensure appropriate care of residents by not seeking medical attention for R1, which poses an immediate health, safety and personal rights risk to residents in care.
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Type A
06/22/2022
Section Cited

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 87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of
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admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement was not met as evidenced by Based on observation and record review Licensee did not report covid positive to CCLD which poses an immediate health, safety and personal rights risk to residents in care.
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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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5


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: 06/20/2022
NARRATIVE
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Office meeting will be scheduled. LPA's requested a copy of LIC308, LiC500, current control of property by 6/22/22. LPA's provided a copy of provider information notification for Covid 19 guidelines and home care organization list.

Deficiencies are being cited on 809D. Civil Penalties were issued.

An exit interview and a copy of this report was provided along with Plans of Correction and Appeal Rights. .
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 06/20/2022 06:30 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: 06/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/22/2022
Section Cited

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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may
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require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. Based on observation and interviews facility does not have sufficient staff to enforce sign in policies, which poses an immediate health, safety and or personal rights risk to residents in care.
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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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5