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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202747
Report Date: 09/14/2021
Date Signed: 09/23/2021 07:53:37 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
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: 41DATE:
09/14/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Ana SainiTIME COMPLETED:
04:25 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
LPA Marybeth Donovan conducted a TA Visit with Lori Kloppinger PCC, Jackie Jin LPM, Anu Saini Licensee, Loria Garrison Med Tech and Sol Spencer Director of Maintenance. The purpose of the visit was to provide technical assistance for Infection Prevention and Control guidelines for Adult and Senior Care facilities. LPA conducted a tour of the facility.

LPA and PCC reviewed the facility policies and procedures to include screening, visitation and social distancing, isolation, staffing, training, PPE usage, Doffing and Donning of PPE, Fit Testing, disinfecting.

The following recommendations were discussed:

1. Post Signs in front of the facility to Do Not Enter for visitors and essential persons without staff screening.

2. Increase disinfecting of common areas and frequently touched surfaces to once per shift.

3. Continue ongoing staff training on infection prevention and control measures.

LPA provided Links to CDC printable posters and copies of the PPE Donning and Doffing signs. RO to provide additional supply of PPEs to the facility.

LPA reviewed recommendations with Ana Saini Licensee and copy emailed for signature.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE:
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 1