277209241-1-3-2024-24-AS-BCHN-CZKRL5-20240117120633

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 277209241
Report Date: 12/21/2023
Date Signed: 01/03/2024 01:37:43 PM

Unsubstantiated

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
07/21/2023 and conducted by Evaluator David Ayers

COMPLAINT CONTROL NUMBER: 24-AS-20230721114455

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:	01:25 PM

ALLEGATION(S):

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Resident developed pressure sores due to staff negligence.
Resident sustained skin lacerations due to staff negligence.
Staff handled resident in a rough manner causing bruising.
Staff spoke inappropriately to resident.

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 Unsubstantiated.
1. Resident developed pressure sores due to staff negligence.
Resident 1 (R1) began receiving hospice care on 6/13/2023. On 4/18/2023, R1 was prescribed with orders from the hospice physician for wound care, which was to be completed 3 times per week, for a wound developing on R1’s right ankle. R1 was seen in the emergency room on 7/7/2023, where it was identified by the attending physician that R1 was developing a pressure sore on his right foot. On 7/14/2023, facility staff updated the needs and service plan to reflect the need for wound care. This care was to be provided by hospice staff.

Unsubstantiated

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-20230721114455

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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2. Resident sustained skin lacerations due to staff negligence.

On 7/7/2023, while in the activity room, R1 received lacerations to his left hand and fingers. According to facility staff, R1 was left unattended for approximately five minutes. R1 was seen in the emergency room, where the attending physician determined that the lacerations were consistent with injuries that would be sustained from R1’s wheelchair.

3. Staff handled resident in a rough manner causing bruising.

R1 complained to their responsible party and to facility staff of being handled roughly. R1 requested that certain staff at the facility no longer provide direct care to him due to what they claim was rough handling. Although R1 did receive bruising to their arms, it is unclear as to whether this was as a result of handling by facility staff. During interviews, facility staff deny handling R1 in a rough manner, and also deny witnessing any staff handle R1 roughly, or in a way which is considered inappropriate.

4. Staff spoke inappropriately to resident.

During interviews, facility staff denied speaking inappropriately to R1, or any other residents. Other facility residents stated that staff provided adequate care for them and felt that they were treated well by staff.

Although these allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. A copy of the report was provided to the licensee vial email and exit interview conducted.

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)

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