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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202747
Report Date: 10/11/2022
Date Signed: 10/11/2022 12:11:55 PM


Document Has Been Signed on 10/11/2022 12:11 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: 38DATE:
10/11/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:Facility Staff, Ashley RiderTIME COMPLETED:
12:25 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
On 10/11/2022, Licensing Program Analysts (LPAs) Walton and Doucette arrived unannounced to deliver findings on complaint #24-AS-20220616140706. During the investigation, LPAs observed additionally deficiencies and conducted a case management- deficiencies visit to address the concerns identified in the complaint. LPAs introduced themselves, stated the purpose of the visit, and requested to meet with the Administrator. The Administrator, Sani Sandeep, was not available during this inspection. Facility staff, Ashley Rider contacted Administrator via telephone. LPAs received verbal permission from Administrator to meet with facility staff.

Upon entry to the facility, facility staff was in the process of destroying medications. Interviews with staff and Administrator confirmed that staff is not the administrator and does not have an administrator's certificate.

During the investigation of the above complaint, it was determined that the facility did not report an incident that occurred with R1 to the Fresno CCL office.

During today's inspection, LPAs reviewed medical records for R1 and observed that the facility did not assist with administering R1's medication from 08/24/2022 - 08/30/2022, and again on 10/08/2022.

Deficiencies are being cited in accordance to California Code of Regulations, Title 22, Division 6, on the attached 809D. An immediate civil penalty in the amount of $250 is being assessed for repeat violation.

An exit interview was conducted and a Plan of Correction was reviewed and developed. A copy of this report and appeal rights were discussed and provided to Facility Staff, Ashely Rider, whose signature on this form confirms receipt of these documents.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022
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 10/11/2022 12:11 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: 10/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/12/2022
Section Cited

1
2
3
4
5
6
7
87465 (a): A plan...shall...provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
8
9
10
11
12
13
14
Based on record review, the Licensee did not ensure the requirements for section 87465(a)(4) were met when the facility did not assist R1 with self-administered medications from 08/24/22-8/30/22 and 10/8/22 which posess an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
8
9
10
11
12
13
14
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) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 10/11/2022 12:11 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: 10/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2022
Section Cited

1
2
3
4
5
6
7
87465(i): (i) Prescription medications which are not taken...shall be destroyed in the facility by the facility administrator and one other adult who is not a resident, this requirement was not met as evidenced by:
8
9
10
11
12
13
14
Based on interviews, the licensee did not ensure the requirements for section 87465(i) were met when facility staff destroyed resident medications.
8
9
10
11
12
13
14
Type B
10/25/2022
Section Cited

1
2
3
4
5
6
7
87211(a)(1): Each licensee shall furnish to the licensing agency...the following: 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). This requirement was not met as evidenced by:
8
9
10
11
12
13
14
Based on interviews and record review, the licensee did not ensure the requirements for section 87211 were met when the facility did not submit a written report regading an incident with R1, this posess a potential healh 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) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3