277209241-4-11-2024-24-AS-BCHN-D5BMSC-20240516095141

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 277209241
Report Date: 04/11/2024
Date Signed: 04/11/2024 01:23:35 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
04/04/2024 and conducted by Evaluator David Ayers

COMPLAINT CONTROL NUMBER: 24-AS-20240404163037

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: 76	DATE:	04/11/2024
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Jessica Sanchez - Executive Director		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Resident's ceiling is leaking water.

INVESTIGATION FINDINGS:

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On 4/11/2024, Licensing Program Analyst(LPA) D. Ayers arrived at the facility unannounced to conduct an initial 10-day complaint inspection. LPA met with Executive Director Jessica Sanchez and announced the purpose of the inspection.

1) Resident's ceiling is leaking water: During the visit, LPA conducted interviews and inspected the facility. LPA toured the bedroom and bathroom of Resident 1 (R1). R1 stated that there had been a leak in their bathroom ceiling, but it was repaired by facility staff. According to facility staff, the leak was repaired on 3/31/2024, and had been leaking for a few days. LPA observed two patches in the ceiling that appeared to be repaired and painted. There were no active leaks in residents' bedrooms at the time of inspection.

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.

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: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

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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