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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 277209241
Report Date: 09/12/2022
Date Signed: 09/12/2022 04:13:18 PM


Document Has Been Signed on 09/12/2022 04:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:PACIFIC GROVE SENIOR LIVINGFACILITY NUMBER:
277209241
ADMINISTRATOR:FAY, SHARONFACILITY TYPE:
741
ADDRESS:551 GIBSON AVENUETELEPHONE:
(831) 657-5200
CITY:PACIFIC GROVESTATE: CAZIP CODE:
93950
CAPACITY:150CENSUS: 62DATE:
09/12/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Sarah Ehret
Sharon Fay
TIME COMPLETED:
04:31 PM
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On 9/12/2022, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Pre licensing Inspection. LPA introduced self and stated purpose of the visit. LPA met with Sarah Ehret, Executive Director and conducted facility tour.

The facility has applied for license under change of ownership. There are currently 62 residents in care, of which 45 are Independent Living and 17 are Assisted Living. The facility also has a Skilled Nursing on site which is licensed by CDPH and was not toured.

Facility tour conducted, facility appeared clean and in good repair. Rooms toured in Independent Living include #318 and #319 toured in main building, #A22 in Cottage, and #31 in West Wing. Room toured in Assisted Living include #242. All medication observed to be locked and secured in medication cart in Assisted Living, additional supplies are locked and secured in medication room. Inside common areas of facility have adequate seating and lighting. Resident rooms are equipped with call buttons that notify nurses station and page staff. All residents are also provided with emergency pendant alarms to wear for assistance.

Kitchen toured, facility is equipped with enough plates, cups, utensils for residents in care. Facility currently receives food deliveries for produce 4-6 times per week, canned goods 2 times per week, dairy 2 times per week and meat/poultry 2-4 times per week. LPA observed facility to have a minimum of 2 day supply of perishable food and a 7 day supply of non-perishable food available.

Water temperature measured at 120 degrees. Fire extinguishers present through out facility, with a service date of 4/18/22. Carbon monoxide detectors present and observed operational. Facility is equipped with pull stations and fire sprinklers.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: PACIFIC GROVE SENIOR LIVING
FACILITY NUMBER: 277209241
VISIT DATE: 09/12/2022
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Fitness center is primarily available for Independent Living residents with scheduled classes scheduled on activity calendar. Additional modified activities are also available for Assisted Living residents.

LPA observed the required facility postings to include disaster plan, personal rights, discrimination notice, theft and loss policy, facility sketch identifying the emergency exits, CCLD complaint poster and Long Term Care Ombudsman poster.

Outside seating areas have adequate seating and shade available for residents.

Component III was conducted with Sarah Ehret, Executive Director and Sharon Fay, BSN RN/Administrator.

Pre-Licensing is complete and this facility has no deficiencies.


SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022
LIC809 (FAS) - (06/04)
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