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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 277209241
Report Date: 12/21/2023
Date Signed: 03/14/2024 08:47:30 AM


Document Has Been Signed on 03/14/2024 08:47 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
SIERRA CASCADE AC/SC, 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: 75DATE:
12/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Billt Mitchell - Interim Executive Director TIME COMPLETED:
01:30 PM
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On 12/21/2023, Licensing Program Analyst(LPA) D. Ayers arrived unannounced to conduct a Required Annual Inspection. LPA met with Interim Executive Director Billy Mitchell and announced the purpose of the visit.

LPA toured the assisted living section located on the 2nd floor. Resident bedrooms and bathrooms were clean and odor free. Bedrooms had required minimum furnishings. Bathrooms had required secure grab bars and non-skid mats. Resident dining area was clean and free from hazards. Sharp items, chemicals, and detergents were secured in a locked cabinet within the kitchen area. LPA reviewed a sample of resident files, which contained required documents and records. There were two caregivers and a Resident Services Director is the assisted living section providing care and supervision to residents.

LPA toured the facility main kitchen and dining area. The kitchen was clean, and all food items were observed to be stored and labeled properly. The facility had an adequate supply of perishable and nonperishable foodstuffs. LPA observed a supply of emergency food and potable water which was stored adjacent to the down stairs parking garage.

LPA reviewed a sample of staff files and the facility emergency disaster plan.

No deficiencies were cited during the inspection. A copy of the report was provided and exit interview conducted with Administrator.

Executive Director agreed to send CCLD the following documents by 12/29/2023: LIC610E, LIC500, LIC9020, and a sample admission agreement.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David AyersTELEPHONE: 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.

LIC809 (FAS) - (06/04)
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