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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 02:27:24 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
07/13/2021 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20210713150602
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:
09:58 AM
MET WITH:Gloria KumerTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility Administrator is not at the facility a sufficient number of hours
Menus are not made available to residents
Facility does not post planned activities

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to deliver findings for the allegations listed above.

Based on observation, interviews with staff (Gloria), records reviewed and posted. The facility last menu for dining was posted with a date of February 2022 for both the menu and the activities schedule. LPA also observed in the kitchen a menu dated for the time period of 10/17/2021 thru 10/30/2021. Kitchen Staff (Santa) confirmed that she make the meals according to what the facility has and there is no menu posted. LPA interviewed three residents and was told that there is no scheduled activities and they are left to plan for themselves for the day. Staff confirmed that the Activities Director resigned a week after Valentines day and no new Activities Director has been hired.

Based on the tour of the facility and the substantiated allegation on this report and others the Administrator is not at the facility enough to provide guidance and leadership to remain in compliance with regulatory requirements. The Administrator is on location two times per week this was confirmed by staff on today's inspection.

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.

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 3
Control Number 26-AS-20210713150602
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
CCR
87405(a)
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Administrator – Qualifications and Duties. All facilities shall have a certified administrator with enough freedom from other responsibilities and a sufficient number of hours on the premises to give adequate attention to the administration of the facility.
This requirement was not met as
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Licensee will ensure that The Administrator take a minimum of 20 hours of training including but not limited to the following: Title 22 regulations, staff training, effective
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evidenced by the lack of attention to administration of the facility with posting of required information for the residents and substantiated allegations. This poses a health risk to residents in care.
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communication and record keeping and documentation. Training topics and dates 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
Type B
03/18/2022
Section Cited
CCR
87555(b)(6)
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87555(b)(6) The following food service requirements shall apply:
(6) In facilities for sixteen (16) persons or more, menus shall be written at least one week in advance and copies of the menus as served shall be dated and kept on file for at least 30 days. Facilities licensed for less than sixteen (16) residents shall maintain a sample menu in their file. Menus shall be made available for review by the residents or their designated representatives and the licensing agency upon request.

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Licensee will conduct a staff training with kitchen staff to ensure understanding regulation. Licensee will submit training agenda and staff sign off sheet by POC date 3/18/2022
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This regulation was not met by evidence of menus not posted, update, or out of date. This poses a
potential health risk to residents in care.
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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)
Page: 2 of 3
Control Number 26-AS-20210713150602
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 B
03/18/2022
Section Cited
CCR
87219(d)
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87219 Planned Activities
(d) In facilities licensed for seven (7) or more persons, notices of planned activities shall be posted in a central location readily accessible to residents, relatives, and representatives of placement and referral agencies. Copies shall be retained for at least six (6) months.
This requirement is not met as evidenced by:
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The licensee shall create, post, and implement a current activity calendar. The licensee shall maintain on file at least 6 months of activity calendars.
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Based on observation and interview, the licensee failed to post a notice of planned activities in a central location. LPA did not observe a posted activity calendar and staff confirmed an activity calendar was not posted. This poses a potential personal rights risk to residents in care.
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The licensee shall provide LPA with a current activity calendar via email by 3/18/2022.
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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)
Page: 3 of 3