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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202747
Report Date: 09/09/2023
Date Signed: 09/15/2023 04:09:08 PM


Document Has Been Signed on 09/15/2023 04:09 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
Lookup Error,
, CA



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: 21DATE:
09/09/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Kay CabucoTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced visit to the facility September 9, 2023, at 9:30am. for a Case Management - Health Checks visit. LPA meet with facility Executive Director Kay Cabuco and explained the purpose of the visit.

LPA Monter toured the facility inside and out.which included; lobby, kitchen, courtyard area, resident buildings, bathrooms and common areas. LPA toured the locked facility medication area and reviewed 3 resident medication records.

While touring the facility, LPA Monter observed the facility laundry room door open at 9:44am. The door was held open with a garbage bin holding the door open. LPA observed no staff in the area and laundry detergent “All” was accessible to residents in care. LPA asked ADM if the laundry room door should remain closed, ADM stated yes, as residents should not have access to Detergents.

Two-day perishable food supplies and seven-day nonperishable food supplies were observed. LPA observed five staff members in the facility during visit which included the following: the executive director, one cook and 3 care givers.

Deficiencies cited today Per Title 22 Regulations during today's inspection. Exit Interview Conducted with Executive Director Kay Cabuco, and a copy of this report along with appeals rights were provided.

This report was written manually and provided to ADM on 09/09/2023. This copy was transcribed to FAS.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 712-2018
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 09/15/2023 04:09 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: 09/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/10/2023
Section Cited
CCR
87705(f)(2)

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87705(f)(2) The following shall be stored inaccessible to residents with dementia: (2) Over-the counter medication...toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement was not met as evidenced by;
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POC: Staff closed door during visit. ADM stated she will send a statement of understanding regarding the need to
keep detergents and other toxics inaccessible to residents in care.
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Based on LPA's observation of the laundry room door being open with laundry detergent being acesssible to residents in care, the facility did not ensure toxics suchs as detergent was inacessible to residents with dementia which poses an immediate health, safety, and personal rights risk to persons 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) 266-8800
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 712-2018
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2023
LIC809 (FAS) - (06/04)
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