275202747-11-22-2023-24-AS-BCHN-CY9RNQ-20231206121043

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 275202747
Report Date: 10/04/2023
Date Signed: 11/22/2023 08:42:49 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
05/24/2023 and conducted by Evaluator David Ayers

COMPLAINT CONTROL NUMBER: 24-AS-20230524150223

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:	10/04/2023
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Anu Saini - Licensee		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident needs are not being met

INVESTIGATION FINDINGS:

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On 10/4/2023, Licensing Program Analyst (LPA) D. Ayers conducted an unannounced complaint inspection. LPA conacted Licensee Anu Saini via telephone and announced the purpose of the visit. Licensee agreed to receive and review the report via email. 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 5/16/2023, Resident 1(R1) was experiencing doscomfort and required assistance. R1 attempted to request assistance from facility staff, but staff did not respond until change of shift later that afternoon. During interview, R1 stated that they waited for hours for assistance. 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 to the licensee via email. Appeal Rights (LIC 9058) were provided to the licensee, who signed the original copy of this report.

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: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

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-20230524150223

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: 10/04/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/04/2023 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 specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below...This requirement was not met as evidenced by:	1 2 3 4 5 6 7	SInce 5/16/2023, the licensee has hired and trained new staff to include: an Executive Director, Resident Care Director, Activities Coordinator. The licensee has hired four live-in staff who are able to cover shifts as needed and better meet the needs of the residents. Deficiency is cleared.
	8 9 10 11 12 13 14	Based on interviews, the licensee did not ensure that the needs of at least one out of 24 residents' needs were met on 5/16/2023, which presents a potential risk to the health and safety of 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: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC9099 (FAS) - (06/04)

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