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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 275202747
Report Date: 07/27/2023
Date Signed: 08/01/2023 09:12:56 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
04/19/2023 and conducted by Evaluator David Ayers
COMPLAINT CONTROL NUMBER: 24-AS-20230419101950
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: 26DATE:
07/27/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Syed Majid - AdministratorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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-Staff failed to seek medical attention in a timely manner for resident who fell and sustained serious injury while in care.
-Staffing is insufficient to meet the needs of the residents.
-Facility failed to report serious incident.
INVESTIGATION FINDINGS:
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On 7/27/2023, Licensing Program Analyst (LPA) D. Ayers conducted an unannounced complaint inspection at 0900 hours. LPA met with Administrator Syed Majid. 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 04/19/2023, the Department received a complaint regarding a resident (Resident 1) sustaining a fall and not provided timely medical assistance. The initial complaint inspection was conducted on 04/20/2023. R1 sustained a fall and had a big bump on R1’s forehead on 04/08/2023, at approximately 1713 hours. Staff (S1) who was working by herself in the assisted living area, saw R1 and asked for help from another staff (S2). S2 went to next door and called staff (S3) for help. Staff placed R1 back on R1’s wheelchair, and S1 wheeled R1 to R1’s bedroom. The ambulance was called at 1742 hours. According to facility administrator, if a resident sustains a fall and has any sign of injury, staff are not to move them. Staff are also to call 911 immediately, within five (5) minutes.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David AyersTELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023
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
Control Number 24-AS-20230419101950
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: 07/27/2023
NARRATIVE
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Facility staff did not report this incident to the department.

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 allegations are 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. At the time of the complaint inspection on 7/27/2023, licensee was informed that the incident is currently under review and a future civil penalty may apply based on Health and Safety Code § 1569.49.

An exit interview was conducted, and a copy of this report provided. Appeal Rights (LIC 9058) was provided to the administrator, whose signature below confirms receipt of these rights.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 24-AS-20230419101950
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: 07/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/28/2023
Section Cited
CCR
87465(g)
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87465 INCIDENTAL MEDICAL AND DENTAL CARE SERVICES 87465 (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident's health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469 (c)(2), (c)(3), or (c)(4).
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Licensee stated that staff training on facility emergency response policy will be conducted on 7/28/2023. Licensee 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.
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This requirement is not met as evidenced by: Based on interviews and reviews of evidence, licensee failed to immediately telephone 9-1-1 after R1 had a fall resulting in hospitalization which poses an immediate 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: 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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 24-AS-20230419101950
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: 07/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/04/2023
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.
This requirement was not met as evidenced by:
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The licensee w has agreed to increase staffing and competency in order to meet the needs of the residents. CCLD will continue to monitor the facility.
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Based on interviews and records review, staff were not competent enough and/or sufficient in numbers to properly meet the needs of the residents, which poses a potential risk to health, safety, and personal rights of the residents in care.
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Type B
08/04/2023
Section Cited
CCR
87211(a)(1)(B)
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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) (B)Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement was not met as evidenced by:
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The licensee has agreed to provide training to staff regarding proper reporting procedures.
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Based on interviews and records review, facility staff did not report the incident which occurred 4/8/2023, and resulted in the injury of R1, to CCLD within the required timefarme.
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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: 559-498-4163
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
LIC9099 (FAS) - (06/04)
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