275202747-9-15-2023-24-AS-BCHN-CX7SZH-20231102141910

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 275202747
Report Date: 09/15/2023
Date Signed: 09/15/2023 11:11:49 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
05/04/2023 and conducted by Evaluator David Ayers

COMPLAINT CONTROL NUMBER: 24-AS-20230504121510

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:	09/15/2023
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Sandeep Saini - Licensee		TIME COMPLETED:	11:40 PM

ALLEGATION(S):

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Resident sustained an unexplained injury while in care.
Facility did not provide adequate supervision resulting in resident eloping from facility.
Facility did not report an incident to licensing.

INVESTIGATION FINDINGS:

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On 9/15/2023, Licensing Program Analyst (LPA) D. Ayers conducted an unannounced complaint inspection. LPA met with Licensee Sandeep Saini and announced the purpose of the visit. 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.

During the course of the investigation, the department inspected the facility, conducted interviews, and reviewed records. On 7/29/2022, Resident 1(R1) was found in the neighborhood surrounding the facility. Facility staff were notified by paramedics that R1 was found and had sustained injuries. Due to the injuries, R1 was admitted and treated at Natividad Hospital in Salinas, CA for approximately a month. R1's primary diagnosis was dementia, according to her most recent physician's report dated 11/29/2019. Although facility staff did report this incident to Community Care Licensing Division(CCLD), the report was incomplete and did not include required information. No subsequent incident reports were received regarding the resident or their status.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David Ayers	TELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

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-20230504121510

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: 09/15/2023

NARRATIVE

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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 the attached LIC 9099-D. Failure to correct the deficiency may result in civil penalties.
An exit interview was conducted, and a copy of this report provided. Appeal Rights (LIC 9058) were provided to the administrator, whose signature below confirms receipt of these rights.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David Ayers	TELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 24-AS-20230504121510

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: 09/15/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/18/2023 Section Cited CCR 87464(d)	1 2 3 4 5 6 7	87464 Basic Services:(d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal...and providing the other basic services...either directly or through outside resources. The licensee did not ensure this requirement was met as evidenced by:	1 2 3 4 5 6 7	The licensee has hired a new Administrator and Resident Care Director, as well as increased staffing. The licensee has provided written plan to CCLD in order to maintain complaince and ensure the needs of residents are met.
	8 9 10 11 12 13 14	Based on records review and interviews, the licensee did not ensure that at least 1 out of 32 residents needs were met on 7/29/2022, resulting in to a resident elopement and injury, which presented an immediate risk to the health and safety 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
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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) 266-8889
LICENSING EVALUATOR NAME: David Ayers	TELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 24-AS-20230504121510

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: 09/15/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/22/2023 Section Cited CCR 87464(f)(4)	1 2 3 4 5 6 7	87464 Basic Services(f)(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The facility has hired a new Administrator and Resident Care Director, as well as increased staffing. The Licensee has provided a written statement agreeing to maintain compliance and provide adequate care to the residents.
	8 9 10 11 12 13 14	Based on observation and records reviewed, the licensee did not ensure that appropriate care and assistance was provided to at least 3 out of 32 residents in care, which presented a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 09/22/2023 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	87211 Reporting Requirements:(a)(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.	1 2 3 4 5 6 7	The licensee has agreed to provide training to staff to ensure that complete incident reports are provideed to CCLD in a timely manner, and provide proof of training by POC due date.
	8 9 10 11 12 13 14	Based on records reviewed, the licensee did not ensure that a complete incident report was provided for an incident which occurred on 7/29/2022 involving Resident 1, which presented a potential health and safety risk to the residents in care.	8 9 10 11 12 13 14

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) 266-8889
LICENSING EVALUATOR NAME: David Ayers	TELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4