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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 277209241
Report Date: 02/15/2024
Date Signed: 02/16/2024 04:07:58 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
08/24/2023 and conducted by Evaluator David Ayers
COMPLAINT CONTROL NUMBER: 24-AS-20230824132408
FACILITY NAME:PACIFIC GROVE SENIOR LIVINGFACILITY NUMBER:
277209241
ADMINISTRATOR:FAY, SHARONFACILITY TYPE:
741
ADDRESS:551 GIBSON AVENUETELEPHONE:
(831) 657-5200
CITY:PACIFIC GROVESTATE: CAZIP CODE:
93950
CAPACITY:150CENSUS: 76DATE:
02/15/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jessica Sanchez - Executive DirectorTIME COMPLETED:
11:25 AM
ALLEGATION(S):
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Facility staff are not providing services agreed to in the Admissions Agreement.
Facility staff are not adhering to food service requirements.
INVESTIGATION FINDINGS:
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On 2/15/2024, Licensing Program Analyst (LPA) D. Ayers conducted an unannounced complaint inspection. LPA met with Executive Director Jessica Sanchez 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. Facility staff are not providing services agreed to in the Admissions Agreement. Based on records review and interviews, facility staff have been providing the services which have been agreed upon in the admissions agreement. "24 hours emergency response with Nurse oversight" was provided to the residents in the assisted living section of the facility, per the agreement.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David AyersTELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
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-20230824132408
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: 02/15/2024
NARRATIVE
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2. Facility staff are not adhering to food service requirements- during multiple facility inspections, facility food service was found to meet the requirements set forth by California Code of Regulations and Health and Safety Code. The food was sufficient in both quantity and quality, and was stored properly. Snacks are provided to residents between meals, and residents stated that the food is adequate.

Although the 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.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David AyersTELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC9099 (FAS) - (06/04)
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