<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 277209241
Report Date: 10/18/2024
Date Signed: 10/19/2024 05:59:36 PM

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
10/15/2024 and conducted by Evaluator Vadim Gorban
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20241015104513
FACILITY NAME:PACIFIC GROVE SENIOR LIVINGFACILITY NUMBER:
277209241
ADMINISTRATOR:JESSICA SANCHEZFACILITY TYPE:
741
ADDRESS:551 GIBSON AVENUETELEPHONE:
(831) 657-5200
CITY:PACIFIC GROVESTATE: CAZIP CODE:
93950
CAPACITY:150CENSUS: 76DATE:
10/18/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Melissa Arago, Business Office ManagerTIME COMPLETED:
04:09 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility has no hot water or heat for the residents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/18/2024, Licensing Program Manager (LPM) Brenda Chan and Licensing Program Analyst (LPA) V Gorban arrived at the facility unannounced to conduct a subsequent visit and met with Business Office Manager (BOM) Melissa Arango to deliver findings of above allegation. LPA explained the purpose of the visit.
Allegation: Facility has no hot water or heat for the residents.

Based on observations, interviews, and records reviews residents did not have access to hot water on 10/14 (98 degrees F), 10/15 (98 degrees F) and 10/17 (97 degrees F) in South Wing Building due to boiler stops hearting water and has to be reset mannualy by staff. The facility's broiler igniter is not working properly, and the facility has been intermittently without hot water in the South Wing Building. Based on interviews conducted, observation, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations being cited on the attached LIC 9099-D

Exit interview conducted, copy of this report provide to facility with Appeal Rights
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
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 2
Control Number 24-AS-20241015104513
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: 10/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/19/2024
Section Cited
CCR
87303(e)(2)
1
2
3
4
5
6
7
87303 Maintenance and Operation (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement was not observed as evidenced by:
1
2
3
4
5
6
7
The hot water is ongoing issue. The Licensee agrees to submitt plan of correction by tomorrow. In the plan the facility administrator will provide resolution including timeline to have this completed by and documentation of the complanies who were contacted, when they came out, the issues that were found, and the repairs that are needed, and when they are made.
8
9
10
11
12
13
14
The facility failed to maintained water temperature within regulatory requirement of Titlte 22 regulation (105 degree F (41 degree C) and not more than 120 degrees F) .At a minimum, there were three days, from 10/14, to 10/17 hot water was not accesible to residents. This is poses immediate health and safety risk to persons 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.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2