277209241-1-3-2024-24-AS-BCHN-CZKRJP-20240117120412

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 277209241
Report Date: 12/21/2023
Date Signed: 01/03/2024 11:23:29 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
05/25/2023 and conducted by Evaluator David Ayers

COMPLAINT CONTROL NUMBER: 24-AS-20230525162743

FACILITY NAME:	PACIFIC GROVE SENIOR LIVING		FACILITY NUMBER:	277209241
ADMINISTRATOR:	FAY, SHARON		FACILITY TYPE:	741
ADDRESS:	551 GIBSON AVENUE		TELEPHONE:	(831) 657-5200
CITY:	PACIFIC GROVE	STATE: CA	ZIP CODE:	93950
CAPACITY:	150	CENSUS: 75	DATE:	12/21/2023
		UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Billy Mitchell - Interim Executive Director		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility in disrepair.

INVESTIGATION FINDINGS:

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On 12/21/2023, Licensing Program Analyst (LPA) D. Ayers conducted an unannounced complaint inspection. LPA met with Billy Mitchell and announced the purpose of the inspection. 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. The following allegations have been determined to be Substantiated:

Facility in Disrepair - During an inspection on 5/31/2023, LPA observed an active leak from water pipes which were running along the ceiling of the underground resident parking garage. LPA observed a puddle which had formed as a reulat of the leak, approximately 20 feet by 10 feet in size, and over an inch deep at its deepest point. At the time of inspection, the body of water had not been marked or blocked off by facility staff.

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: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

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-20230525162743

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: PACIFIC GROVE SENIOR LIVING	FACILITY NUMBER: 277209241
	VISIT DATE: 12/21/2023

NARRATIVE

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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.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David Ayers	TELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 24-AS-20230525162743

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: PACIFIC GROVE SENIOR LIVING	FACILITY NUMBER: 277209241
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/21/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/22/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	A work order had been placed to repair the leak on 5/31/2023. LPA verified that the leak was repaired and the area was free from hazards on 7/13/2023. Deficiency cleared.
	8 9 10 11 12 13 14	Based on obervation and interview, the licensee failed to ensure that the facility was in good repair and free from hazard around the time of 5/25/2023-5/31/2023, which presented a potential risk to the health and safety of residents in care.	8 9 10 11 12 13 14
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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: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David Ayers	TELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC9099 (FAS) - (06/04)

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