275202747-10-9-2023-24-AS-BCHN-CWGTMZ-20231010145159

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 275202747
Report Date: 09/29/2023
Date Signed: 10/09/2023 08:55:45 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 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
07/21/2023 and conducted by Evaluator Sarah Hurt

COMPLAINT CONTROL NUMBER: 24-AS-20230721163139

FACILITY NAME:	DEL MONTE ASSISTED LIVING FACILITY, THE		FACILITY NUMBER:	275202747
ADMINISTRATOR:	SANDEEP SAINI		FACILITY TYPE:	740
ADDRESS:	1229 DAVID AVE		TELEPHONE:	(831) 375-2206
CITY:	PACIFIC GROVE	STATE: CA	ZIP CODE:	93950
CAPACITY:	49	CENSUS: 24	DATE:	09/29/2023
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Facility Medication Technician, Tania Baria		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility does not have sufficient staff to meet resident needs
Reporting requirements

INVESTIGATION FINDINGS:

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On 09/29/2023, Licensing Program Analyst(LPA) Sarah Hurt arrived at the facility unannounced to deliver findings on complaint allegations listed above. LPA met with Facility Medication Technician Tania Baria announced the purpose of the inspection.

Regarding the allegation Facility does not have sufficient staff to meet resident needs. LPA Hurt interviewed three facility caregivers. Two of the three caregivers stated the facility is short staffed, and more caregivers are needed especially on overnight shifts. Staff 1 stated there was recently an overnight shift where one staff was responsible for the residents in Assisted Living, and Memory care. Based on the interviews 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. The facility was previously cited for Personnel Requirements on 09/22/2023. Please reference complaint #24-AS-20230710075809 to view citing.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 24-AS-20230721163139

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: DEL MONTE ASSISTED LIVING FACILITY, THE	FACILITY NUMBER: 275202747
	VISIT DATE: 09/29/2023

NARRATIVE

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...Continued

Regarding the allegation Reporting requirements. LPA Hurt reviewed facility records documenting Resident 1 falling dated 03/02/2023, 04/28/2023, 06/01/2023. These incidents were not reported to Licensing. Based on the records 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.

The following Deficiencies are being cited Per Title 22 Regulations.

Exit interview conducted with facility Medication Technician Victoria Montoya, and a copy of this report along with appeals rights provided.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 24-AS-20230721163139

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 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: 09/29/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/13/2023 Section Cited CCR 87211(a)	1 2 3 4 5 6 7	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) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.The follwojg requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Administrator agrees to conduct staff training on reporting requirements and submit proof to LPA Hurt by 10/13/2023 POC date.
	8 9 10 11 12 13 14	LPA Hurt reviewed facility records documenting several falls for facility Resident 1 that were not reported to Licensing which poses a potential health, safety, or personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
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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 Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC9099 (FAS) - (06/04)

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