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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202747
Report Date: 07/27/2023
Date Signed: 08/07/2023 03:22:18 PM


Document Has Been Signed on 08/07/2023 03:22 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
SIERRA CASCADE AC/SC, 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: 27DATE:
07/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Syed Majid - AdministratorTIME COMPLETED:
01:30 PM
NARRATIVE
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On 7/6/2023, Licensing Program Analyst(LPA) D. Ayers arrived unannounced at the facility to conduct a Required Annual Inspection. LPA met with Administrator Syed Majid and announced the purpose of the inspection. Administrator certificate was current with renewal date 10/1/2023.

LPA toured the facility inside and outside. Passageways and exits were clear and free from obstruction. Smoke-detectors and carbon-monoxide detectors were present and operational. Facility was clean and odor free. LPA observed sufficient amount of perishable and non-perishable foodstuffs. Common areas were clean, adequately furnished, and adequately lit. Resident bedrooms were clean and had required minimum furnishings. Resident bathrooms were clean, odor free, and water temperature was within required temperature range. Sharp items were secured in a locked drawer. A locked room was observed to store resident medications, and medications appeared to be administered properly. LPA reviewed facility plan of operations and emergency disaster plan. LPA reviewed a sample of staff and resident files. At 12:00 pm, during review of resident files, LPA observed that the admission agreement for Resident 1(R1) did not have a basic rate listed in the agreement. Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, this deficiency was observed and cited on LIC 9099-D.

CCLD requested the following documents to update the facility file: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan, LIC 9020 Regirtser of Facility Residents, and a copy of current Administrator’s Certificate.
No deficiencies were cited during the inspection. Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David AyersTELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/07/2023 03:22 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
Lookup Error,
, CA


FACILITY NAME: DEL MONTE ASSISTED LIVING FACILITY, THE
FACILITY NUMBER: 275202747

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of six files reviewed, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2023
Plan of Correction
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Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David AyersTELEPHONE: 559-408-4163
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
LIC809 (FAS) - (06/04)
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