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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 275202747
Report Date: 03/30/2023
Date Signed: 04/13/2023 03:28:16 PM

Unsubstantiated


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
11/17/2022 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 24-AS-20221117133617
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: 25DATE:
03/30/2023
UNANNOUNCEDTIME BEGAN:
04:05 PM
MET WITH:Syed MajidTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff caused injuries to resident
Resident sustained fractures while in care
Staff handle residents in a rough manner
Staff failed to meet residents' needs
Staff failed to provide a safe environment for residents in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on a complaint investigation. LPA Hurt met with facility Administrator, Syed Majid and explained the purpose of today's visit.

Regarding the allegation Staff caused injuries to resident. Based on observation, records reviewed, and interviews the facility staff did not cause injury to Resident 1. Resident 1's Physician, and Responsible party both stated they do not suspect abuse is the cause for injuries to Resident 1. Resident 1 was taken to the hospital on 10/11/2022, and the medical report does not document any suspected abuse. This allegation is UNSUBSTANTIATED, meaning although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Continued..







Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
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
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
11/17/2022 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 24-AS-20221117133617

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: 25DATE:
03/30/2023
UNANNOUNCEDTIME BEGAN:
04:05 PM
MET WITH:Sayed MajidTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility failed to provide adequate food service
Facility failed to provide a comfortable temperature for resident
Staff mismanaged residents medications
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on a complaint investigation. LPA Hurt met with facility Administrator, Syed Majid and explained the purpose of today's visit. LPA Hurt observed during several visits conducted during this investigation on 11/17/2022, and 01/23/2023 the facility refrigerator in the main kitchen area, pantry area, and the smaller resident houses (building #5) with refrigerators had several food containers that are not labeled or dated. The main facility kitchen also stores chemicals near the food storage areas. Based on LPA’s observation the preponderance of evidence standard has been met therefore the above allegation is found to be SUBSTANTIATED.

..Continued

(This is an amended report)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 24-AS-20221117133617
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: DEL MONTE ASSISTED LIVING FACILITY, THE
FACILITY NUMBER: 275202747
VISIT DATE: 03/30/2023
NARRATIVE
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..Continued

Regarding the allegation Facility failed to provide a comfortable temperature for resident. LPA Hurt has visited the facility several times including on 11/17/2022, 01/23/2023, 03/25/2023, each time Resident 1’s bedroom door is open, and the room temperature is under 68 degrees which is the minimum required by Title 22 regulations. Resident 1 is in a wheelchair, and he is unable to close the door behind him causing the door to consistently remain open as he goes in and out. Based on LPA’s observation the preponderance of evidence standard has been met therefore the above allegation is found to be SUBSTANTIATED.

Regarding the allegation Staff mismanaged residents' medication Based on LPA observation, and records reviewed during the course of this investigation the facility staff has mismanaged residents medications. During a visit to the facility on 11/30/2022 LPA's observed a bubble pack containing Resident 2's Hydroco/APAP 10-325, directions (take 1 tablet by mouth twice daily), filled on 09/20/2022 to have 14 pills missing. LPA reviewed a document titled "Controlled Substance Quantity Count Record" to have only one pill accounted for taken on 11/06/2022. The preponderance of evidence standard has been met therefore the above allegation is found to be SUBSTANTIATED. The facility was recently cited for similar allegations after an investigation refer to complaint 26-AS-20211228115517 citing dated 02/06/2023 . No further citing will be issued at this time.


The following Deficiencies are being cited Per Title 22 Regulations

Exit interview conducted with Administrator Sayed Majid. A copy of this report along with appeals rights provided.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 24-AS-20221117133617
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: 03/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/13/2023
Section Cited
CCR
87303(b)(1)
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87303 Maintenance and Operation
.(b) A comfortable temperature for residents shall be maintained at all times.
(1) The facility shall heat rooms that residents occupy to a minimum of 68 degree F, (20 degrees C). The following requirement has not been met as evidenced by:
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Administrator Syed Majid will provide a written plan to ensure all facility residents bedroom are within the temperature required in regulations and send to LPA Hurt by POC date of 04/13/2023.
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LPA Hurt observed Resident 1's room to be below 68 degrees on several visits to the facility which poses a potential health, safety or personal rights risk to residents in care.
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Type B
06/01/2023
Section Cited
CCR
87555(a)
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87555 General Food Service Requirements(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. The following requirement has not been met as evidenced by:
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Licensee will provide training for facility kitchen staff on food safety, and proper storage, and provide proof to LPA by POC date of 06/01/2023.
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LPA Hurt observed on two separate visits to facility, food in the refrigerator with no date or label, LPA also observed chemicals close to food storage areas, which poses a potential, health, safety, 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: Stephenie DoubTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 24-AS-20221117133617
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: 03/30/2023
NARRATIVE
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Regarding the allegation Resident sustained fractures while in care. Based on interviews, and records reviewed during this investigation. Resident 1 has a history of falling and was taken to the hospital on 10/10/2022 for right rib and hip pain, there were no fractures identified during the hospital visit on 10/10/2022. According to facility incident reports, and Resident 2, (Resident 1’s former roommate) Resident 1 would often fall in her room. This allegation is UNSUBSTANTIATED, meaning although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation Staff handle residents in a rough manner. Based on records reviewed, and interviews conducted during this investigation Resident 1 has made allegations of a staff member handling them rough, but the staff name provided is not and has never been an employee at the facility. LPA Hurt interviewed four facility residents all stated the facility staff has never been rough when assisting them. This allegation is UNSUBSTANTIATED, meaning although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.


Regarding the allegation Staff failed to meet residents' needs. Based on interviews conducted during the course of this investigation the facility staff does meet the residents needs. LPA Hurt interviewed four facility residents. The four facility residents all stated the staff assists with them with their needs on a regular basis. This allegation is UNSUBSTANTIATED, meaning although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is

Staff failed to provide a safe environment for residents in care. Based on interviews conducted during the course of this investigation the facility is providing a safe environment for residents in care. LPA Hurt interviewed 5 facility residents and all besides Resident 1 stated they feel safe at the facility. This allegation is UNSUBSTANTIATED, meaning although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

No Deficiencies Cited per Title 22 Regulation. Exit interview conducted with Administrator Syed Majid. A copy of this report provided.

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4