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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 275202747
Report Date: 03/06/2022
Date Signed: 04/05/2022 12:48:10 PM

Substantiated


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
11/10/2021 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20211110163949
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:
03/06/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Loria GarrisonTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility is not following COVID procedures.
Residents are not getting proper and adequate food and on time.
Facility lacks sufficient staff to meet residents’ needs.
Residents are left in soiled clothing for extended periods of time.
Residents are not receiving assistance with activities of daily living.
Residents did not receive medications.
Residents are not being adequately supervised.
Residents’ medications and records are being mismanaged.
INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 03/06/2022 by Licensing Program Analyst Charlie Yang who was met by the manager on duty, Loria Garrison, who was briefly interviewed.
Current census was 48 residents.
The purpose of this visit was to complete the complaint investigation and present the findings to this facility and it's representative at this time.
Based on observation, this facility was not following the policies and procedures set forth in their mitigation plan when dealing with residents, staff, and visitors related to COVID 19. It was observed that the table set up to screen visitors upon entrance to this facility was unmanned for extended periods of time. Visitors were expected to self evaluate, fill out the necessary sign-in document, and supply their information after taking their respective temperatures. It was observed that many visitors would bypass this station and head directly to their loved ones. This was also true for oncoming staff who did not bother to follow through with the procedures set forth in this facility's mitigation plan.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2022
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 6
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
11/10/2021 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20211110163949

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:
03/06/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Loria GarrisonTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility is not maintained clean and sanitary.
Facility does not have emergency food supplies.
Facility dishes are not properly sanitized.
Facility is not following proper food handling techniques.
Facility cleaning products are not properly used and stored.
Facility has pests.
Residents’ medications are not locked.
Facility has residents requiring a higher level of care.
Uncleared adult at the facility.
INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 03/06/2022 by Licensing Program Analyst Charlie Yang who was met by the manager on duty, Loria Garrison, who was briefly interviewed.
Current census was 48 residents.
The purpose of this visit was to complete the complaint investigation and present the findings to this facility and it's representative at this time.
Tour of this facility was conducted. Kitchen area was toured. A review of the facility food supply was conducted for adequate 2-day perishable and 7-day non perishable quantities which was observed to be present at this time.
A review of the dishwasher and sanitation procedures for washing and sanitizing dishes used for cooking and serving unto the residents was conducted. Based on a review of the procedures and available equipment, it was observed that this facility was properly washing and santizing dishes with functional equipment at this time.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 26-AS-20211110163949
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: 03/06/2022
NARRATIVE
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Based on a review of the facility roster for all shifts and personnel present during those shifts, this information was cross referenced with the LIS 536. It was observed that there were three separate shifts for AM, PM, and NOC. Facility personnel were observed to be fingerprint cleared and properly associated at this time.
Based on a sample tour of the facility cottages, resident rooms, and common areas were observed to be clean and sanitary at this time. Based on observation, trash cans were regularly emptied without any unwanted odors at this time. Carpets and flooring were maintained and kept free of debris at this time.
A review of the facility storage unit for housekeeping supplies was conducted. It was observed to be locked and made inaccessible to the residents at this time.
Based on a review of the facility medication room, it was observed to be locked and made inaccessible to the residents in care at this time. An electronic keypad was used as a security measure at this time. It was learned that staff trained in medication management only had access to this key code along with the facility designated Administrator and administrative team.
This facility is licensed to retain and accept up to 49 residents at any given time. A review of the facility License also stated that it had the program to retain and accept dementia residents as well. A hospice waiver was granted for this facility to be able to accept and retain up to (6) residents under hospice care.
In addition, this facility was fire cleared to be able to retain up to (31) residents who were deemed to be bedridden.
Based on a review of the current residents and their levels of care, it was observed that the facility residents have been admitted under the appropriate assessment and within the confines of this facility License and program.
As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.

There were no deficiencies observed or cited at this time.

Exit Interview
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 26-AS-20211110163949
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: 03/06/2022
NARRATIVE
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Based on interviews and observation during this investigation, it was found that staffing was an ongoing issue for this facility. This facility was dealing with staff shortages due to COVID 19, as well as, staff calling off for their assigned shifts creating a shortage in personnel. This was reflected in the staffs' inability to properly respond to all care needs and those whom would be available to provide adequate supervision to the residents in care.
Based on interviews, it was learned that care staff were also responsible for disbursing meals to the residents during meal times. Trays supplied with the appropriate type and amount of food would be set up by the kitchen staff aligning the resident name, building, and room number. It was the responsibility of the care staff to deliver all meals to every resident assigned that day to them during these meal periods. By the time it took facility personnel to deliver all meals to the residents in their respective cottages, some of the meals were cold and residents who required assistance with eating were unattended to until all meals were delivered.
Based on interviews and observation, It was learned that this facility comprised of (7) individual cottages housing any where from (6) up to (9) residents depending on the size and floor plan in each cottage. Due to personnel constraints, an average of 4-5 staff persons would be on the AM shift to supply care to all (48) residents spread out over these 7 cottages. In addition, this facility currently had (6) residents under hospice care and (7) residents under the care of home health. This did not even factor into account the amount of care and attention that needed to be concentrated for those residents who were deemed to be incontinent and for the residents who were deemed to be bedridden. It was observed that there was not a sufficient presence of facility personnel able to adequately provide the proper care and supervision unto all residents in care including medication management as well.
As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.
The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

Appeal rights were printed and a copy was given to the facility representative at this time.

Exit Interview
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 26-AS-20211110163949
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/13/2022
Section Cited
CCR
87411(a)
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Personnel Requirements - General

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This facility was found to be deficient as observed that a shortage of personnel
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Facility representative stated that a review of the facility staffing for all shifts will be conducted. A plan for addressing the staff shortages, call offs for each shift, and number of staff required for each shift will be completed and submitted into CCL by the due date prior to enacting any changes.
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led to facility residents' needs not being met on a daily basis whether it was incontinence care, receiving meals, or activities of daily living with medication management.
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Type A
03/07/2022
Section Cited
CCR
87405(d)(2)
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Administrator Qualifications and Duties and/or 87468.1(a)(2) Personal Rights of Residents in All Facilities

Facility is not screening staff and visitors

This facility was found to be deficient as observed that the submitted mitigation plan
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Facility representative stated that a plan will be submitted in regards to how this facility will address the need to have facility personnel present to take the temperature, log in the result, and ask the required questions prior to admitting anyone into this facility. A completed plan will be completed and submitted into CCL by the due date prior to enactment of any
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for COVID 19 related to this facility was not being followed and the screening process was not being conducted on a regular basis for visitors and oncoming staff.
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proposed changes to staffing.
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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 26-AS-20211110163949
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/13/2022
Section Cited
CCR
87465(h)(6)
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Incidental Medical and Dental Care
The following requirements shall apply to medications which are centrally stored:
The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:
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Facility representative stated that all staff responsible for handling and dispensing medications unto the residents will be trained, for no less than (1) hour in duration, on the topics of handling/storing narcotics, maintaining a proper count between shifts, and proper documentation. A statement of correction along with proof of training detailing name of
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This facility was found to be deficient as evidenced by a review of the facility medication documents which revealed that counts for narcotics were not being done consistently with unaccounted for numbers of narcotics being dispensed.
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trainer, topics trained, and attendees will be completed and submitted into CCL by the due date.
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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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6