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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202747
Report Date: 10/19/2023
Date Signed: 11/22/2023 09:05:41 AM


Document Has Been Signed on 11/22/2023 09:05 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:
10/19/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Victoria Montoya - Medication TechnicianTIME COMPLETED:
11:55 PM
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On 10/19/2023, 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 Technician Victoria Montoya and announced the purpose of the inspection.

During the inspection, LPA toured the facility. LPA reviewed medication logs, and observed that all medications appeared to be stored and administered properly. LPA observed facility food supply and food service to be of adequate quality and quantity. LPA toured resident bedrooms and bathrooms. Bedrooms and bathrooms were clean and odor free. At the time of inspection there was one medication technician, two caregivers in assisted living, as well as 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: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023
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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