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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 275202747
Report Date: 03/12/2022
Date Signed: 03/12/2022 02:32:30 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/07/2021 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20210907094627
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: 49DATE:
03/12/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Gloria KumerTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Facility is not following COVID-19 masking protocols.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to deliver findings for the allegation:Facility is not following COVID-19 masking protocols.

Based on observation on this date 3/12/2022 by LPA Martinez staff at the facility was not wearing a mask when LPA Martinez arrived. Staff was advised to put on the mask and complied with the request.

The preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. The following deficiency was observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22. Civil penalties will be assessed by LPA Martinez.

Appeal rights and report given at the conclusion of the visit
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2022
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 2
Control Number 26-AS-20210907094627
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: DEL MONTE ASSISTED LIVING FACILITY, THE
FACILITY NUMBER: 275202747
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/13/2022
Section Cited
HSC
1569.50(a)(3)
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Health and Safety Code 1569.50(a)(3)Conduct Inimical: Conduct which is inimical to health, morals, welfare or safety of either an individual in, or receiving services from the facility or the people of the State of California.
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The Licensee will conduct a training for all staff on the requirements of proper face covering.
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This requirement was not met as evidenced by observation the facility did not follow proper usage of face covering. This poses an immediate health and safety risk to residents in care.
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A date for this training shall be submitted by POC date 3/13/2022. If additional times is need the Licensee will request for additional time in writing by 3/13/2022
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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: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2022
LIC9099 (FAS) - (06/04)
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