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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 277209241
Report Date: 02/21/2024
Date Signed: 03/04/2024 08:26:54 AM


Document Has Been Signed on 03/04/2024 08:26 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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



FACILITY NAME:PACIFIC GROVE SENIOR LIVINGFACILITY NUMBER:
277209241
ADMINISTRATOR:HARRISON, PAULFACILITY TYPE:
741
ADDRESS:551 GIBSON AVENUETELEPHONE:
(831) 657-5200
CITY:PACIFIC GROVESTATE: CAZIP CODE:
93950
CAPACITY:150CENSUS: 77DATE:
02/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Executive Director, Jessica SanchezTIME COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Sarah Hurt arrived at the facility on 02/21/2024 to conduct a Case Management visit. LPA Hurt met with Executive Director, Jessica Sanchez and explained the purpose of todays visit.


LPA Hurt is following up on an incident involving Staff 1, and Resident 1. LPA Hurt collected receipts, and a police report related to the incident involving Staff 1, and Resident 1. LPA Hurt collected "Roommate and Caretaker Agreement." LPA Hurt spoke with Executive Director, Jessica Sanchez, and obtained more details related to the incident. LPA Hurt collected photos of text communication between Staff, and Resposnible party for Resident 1. LPA Hurt collected Power of Attorney documents for Resident 1 provided by Responsible Party.


No deficiencies cited today Per Title 22 Regulation.

Exit interview conducted with Executive Director, Jessica Sanchez, and a copy of this report provided.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024
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 1