275202747-3-28-2023-24-AS-BCHN-CQDTUY-20230329150306

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 275202747
Report Date: 03/25/2023
Date Signed: 03/28/2023 11:16:13 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
09/07/2022 and conducted by Evaluator Sarah Hurt

COMPLAINT CONTROL NUMBER: 24-AS-20220907134137

FACILITY NAME:	DEL MONTE ASSISTED LIVING FACILITY, THE		FACILITY NUMBER:	275202747
ADMINISTRATOR:	SANDEEP SAINI		FACILITY TYPE:	740
ADDRESS:	1229 DAVID AVE		TELEPHONE:	(831) 375-2206
CITY:	PACIFIC GROVE	STATE: CA	ZIP CODE:	93950
CAPACITY:	49	CENSUS: 27	DATE:	03/25/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Administrator, Sayed Majid		TIME COMPLETED:	05:45 PM

ALLEGATION(S):

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Neglect/ Lack of Supervision resulted in serious Injury

INVESTIGATION FINDINGS:

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On March 25, 2023, Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced complaint inspection at 1330 hours. LPA met with Administrator, Sayed . The purpose of this visit is to deliver the finding of the investigation completed by the Department.

LPA conducted a tour of the facility, interior and exterior to ensure there are no potential or immediate health and safety risk at the facility.

On 09/07/2022, the Department received a Suspected Dependent Adult Abuse Report (SOC 341) alleging that a resident (R1) did not receive proper care resulting in developing maggots on R1’s foot. According to Reporting Party, on 09/05/2022, R1 had maggots on R1’s foot wound, R1’s vagina and anus. On 09/06/2022, Reporting Party again noticed that R1 had maggots on R1’s bed and on the exit of R1’s anus. Per Reporting Party, R1’s wound had a strong smell and R1’s bandage had drainage stains. Facility staff were responsible for changing R1’s depends; however, they denied witnessing any maggots until 09/05/2022. The initial complaint inspection was conducted on 09/08/2022.

Continued...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 24-AS-20220907134137

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: DEL MONTE ASSISTED LIVING FACILITY, THE	FACILITY NUMBER: 275202747
	VISIT DATE: 03/25/2023

NARRATIVE

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..Continued

R1 is not able to provide R1’s self-care. R1 was receiving hospice services. Facility staff states that they called hospice; however, hospice staff stated that they never received a call from facility staff.

Based on the interviews conducted, documentation obtained and reviewed, and the information received during this investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated at this time.

Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiency was observed and cited on LIC 9099-D. Failure to correct the deficiency may result in civil penalties.

An exit interview was conducted, and a copy of this report dated March 25, 2023 provided. Appeal Rights (LIC 9058) was provided to Administrator, Sayed Majid whose signature below confirms receipt of these rights.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 24-AS-20220907134137

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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: 03/25/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/26/2023 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	CCR 87465 (a)(1)87465 INCIDENTAL MEDICAL AND DENTAL CARE SERVICES 87465 (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: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator stated that staff training on meeting each resident’s medical needs will be conducted on 03/26/203. Administrator agrees to develop a written plan of correction (POC) describing in writing how facility shall ensure compliance with CCR 87465 and how similar incident related to violation will be prevented in the future for health and safety of residents. POC shall be received in licensing office by fax and/or mail by due date. Failure to meet POC due date may result in a civil penalty of $100 or more per day.
	8 9 10 11 12 13 14	Based on interviews and reviews of evidence, licensee failed to arrange for medical care appropriate to the conditions and needs of resident. R1 did not receive proper care resulting in developing maggots on R1’s foot which poses an immediate health; safety or personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2023

LIC9099 (FAS) - (06/04)

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