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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202747
Report Date: 09/19/2023
Date Signed: 09/19/2023 10:48:43 AM


Document Has Been Signed on 09/19/2023 10:48 AM - 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: 24DATE:
09/19/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Kay Cabuco - AdministratorTIME COMPLETED:
11:00 AM
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On 9/19/2023, Licensing Program Analyst(LPA) D. Ayers arrived unannounced to conduct a case management inspection. The purpose of this inspection was to ensure facility cleanliness, food quality, and resident well being. LPA met with Medication Administrator Kay Cabuco and announced the purpose of the inspection.

During the inspection, LPA toured the facility and inspected resident bedrooms and bathrooms. Bedrooms and bathrooms were clean and odor free. LPA observed facility food supply and food service to be of adequate quality and quantity. LPA inspected facility medications, which appeared to be administered properly. At the time of inspection, there was one medication technician and two caregivers working in assisted living and one caregiver in memory care. No deficiencies were cited during the inspection. A copy of the report was provided and exit interview conducted.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David AyersTELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2023
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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