277209241-3-15-2024-24-AS-BCHN-D3GUMS-20240318154250

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 277209241
Report Date: 03/14/2024
Date Signed: 03/15/2024 08:51:47 AM

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
09/07/2023 and conducted by Evaluator David Ayers

COMPLAINT CONTROL NUMBER: 24-AS-20230907161406

FACILITY NAME:	PACIFIC GROVE SENIOR LIVING		FACILITY NUMBER:	277209241
ADMINISTRATOR:	HARRISON, PAUL		FACILITY TYPE:	741
ADDRESS:	551 GIBSON AVENUE		TELEPHONE:	(831) 657-5200
CITY:	PACIFIC GROVE	STATE: CA	ZIP CODE:	93950
CAPACITY:	150	CENSUS: 75	DATE:	03/14/2024
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Jessica Sanchez - Executive Director		TIME COMPLETED:	10:55 AM

ALLEGATION(S):

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Staff did not assist resident with obtaining prescription for OTC medications.
Staff are not assisting resident with mobility issues.
Staff are not following resident’s modified diet plan.

INVESTIGATION FINDINGS:

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On 3/14/2024, 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. 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. Staff did not assist resident with obtaining prescription for OTC medications. In September of 2023, Resident 1 (R1) returned to the facility from a skilled nursing facility. R1 returned with a new physician's report which indicated she was unable to manage her own medications. Facility staff informed R1 they must keep her medications centrally stored. R1 has since been given doctor's orders to keep some of her own medications, and has been assisted by facility staff in obtaining her prescriptions.

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: 03/14/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

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-20230907161406

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: 03/14/2024

NARRATIVE

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2. Staff are not assisting resident with mobility issues: During interview, R1 has stated that staff provide her with the assistance she needs. R1 stated that during her stay at a skilled nursing facility, the staff there did not provide her with enough assistance retrieving her personal items from her old room at the facility. These staff are not employed by Pacific Grove Senior Living.

3. Staff are not following resident’s modified diet plan: Based off of record review and interview, there was no documentation to show that R1 was given a modified diet plan by her physician. Facility staff do track residents' modified diet plans on a roster, and these diet plans are adhered to by staff.

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. No deficiencies were cited. A copy of the report was provided to the licensee vial email.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David Ayers	TELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

LIC9099 (FAS) - (06/04)

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