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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 275202747
Report Date: 07/27/2022
Date Signed: 08/04/2022 07:06:33 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/18/2022 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20220718155015
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: 37DATE:
07/27/2022
UNANNOUNCEDTIME BEGAN:
11:23 AM
MET WITH:Staff Ashley RiderTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility mismanaged medications.
Residents needs are not being met.
Facility does not have enough staff.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shawna Doucette contacted the facility to commence a complaint investigation. LPA toook COVID-19 pre-cautionary measures. LPA identified herself and discussed the purpose of the visit and the elements of the allegations with Staff Ashley Rider.

Based on Records Review and interviews R5 did not recieve prescribed medications on 7/2/22, 7/3/22, 7/8/22, 7/9/22, and 7/10/22.

Based on observation and records review, R3's 602 states R3 is on a CCHO diet, where R3 was observed eating a non CCHO diet meal for lunch.

Based on records review and interviews, Facility has one staff for all residents on the night shift where two residents require a two person assist.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
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 4
Control Number 24-AS-20220718155015
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/28/2022
Section Cited
CCR
87465(a)(5)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:

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Plan of Correction POC Licensee agrees to submit a plan and conduct staff training on administering medications by POC due date.
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This requirement was not met as evidenced by Licensee did not adminsiter R5's medications on 7/2/22, 7/3/22, 7/8/22, 7/9/22, and 7/10/22. Based on observation and records review R5 did not recieve medications, which poses an immdediate health, safety and or personal rights risk to residents in care.
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Type A
07/28/2022
Section Cited
CCR
87464(d)
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87464 Basic Services (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources.
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Plan of Correction POC Licensee agrees to submit a plan on how the resident's needs will be met by POC due date.
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This requirement was not met as evidenced by Licensee did not meet the needs of R3's special diet. Based on observation and interviews R3's 602 states R3 is on a CCHO diet, where R3 was observed eating a plate full of potatoes and vegetables which poses an immdediate 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: 07/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 24-AS-20220718155015
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/28/2022
Section Cited
CCR
87411(a)
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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 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.
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Plan of Correction POC Licensee agrees to submit a staffing plan by POC due date.

Civil Penalties were issued.
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This requirement was not met as evidenced by Licensee does not have enough staff to meet residents needs. Based on records review and interviews facility has one night shift staff for all residents in facility where two residents require a two person hoyer lift, which poses an immdiate health safety 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: 07/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 24-AS-20220718155015
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/27/2022
NARRATIVE
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Based on LPAs observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division & Chapter number, are being cited on the attached LIC 9099D.

Civil Penalties were issued.


An exit interview was conducted and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4