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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 277209241
Report Date: 06/10/2024
Date Signed: 07/02/2024 12:09:32 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 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
05/29/2024 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 24-AS-20240529114424
FACILITY NAME:PACIFIC GROVE SENIOR LIVINGFACILITY NUMBER:
277209241
ADMINISTRATOR:JESSICA SANCHEZFACILITY TYPE:
741
ADDRESS:551 GIBSON AVENUETELEPHONE:
(831) 657-5200
CITY:PACIFIC GROVESTATE: CAZIP CODE:
93950
CAPACITY:150CENSUS: 73DATE:
06/10/2024
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Executive Director, Jessica SanchezTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility is without hot water
Facility is without heat
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to conduct a complaint on the allegations listed above. LPA met with Facility Executive Director, Jessica Sanchez, and explained the purpose of today's visit.

Regarding the allegation, Facility is without hot water. The facilities broiler igniter is not working properly, and the facility has been intermittently without heating, and hot water in facility south wing since 05/25/24. The facility is in the process of repairing the boiler igniter, and putting a plan in place for residents to have warm water in a vacant room inside the facility. Resident 1 stated they did have to take a cold shower recently, and was not aware there was a separate room made available for residents to have a warm shower. LPA measured the water temperature in several rooms in south wing of the facility and it measured to be 92 degrees. Based on LPA interviews conducted, observation, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024
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 3
Control Number 24-AS-20240529114424
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: PACIFIC GROVE SENIOR LIVING
FACILITY NUMBER: 277209241
VISIT DATE: 06/10/2024
NARRATIVE
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Regarding the allegation facility is without heat. The facilities broiler igniter is not working properly, and the facility has been intermittently without heating, and hot water since 05/25/24. The boiler igniter is having to be tested and re lit hourly, and when it is not re lit timely the facilities south wing hot water, and heat does not work. The facilities boiler is not currently working at time of visit, and the water temperature measures at 95, and heating in south wing is not working. Based on LPA interviews conducted, observation, and records reviewed which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED

The following Deficiencies are being cited Per Title 22 Regulations.

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: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20240529114424
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PACIFIC GROVE SENIOR LIVING
FACILITY NUMBER: 277209241
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
06/24/2024
Section Cited
CCR
87303(a)(2)
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87303 Maintenance and Operation
(a)(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). The following requirement has not been met as evidenced by:
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Executive director will send proof facility warm water is measuring between 105 and 120 by POC date of 06/24//2024.
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LPA Hurt observed the facility water temperature inside residents south wing bedrooms to measure at 92 degrees, which poses a potential, health, safety, or personal rights risk to residents in care.
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Request Denied
Type B
06/24/2024
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. The following requirement has not been met as evidenced by:
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Executive director will send proof facility heating in south wing is working continuosuly by POC date of 06/24//2024.
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The facilities hot water, and heat has been in disrepair and not working intermittently since 05/25/24, which poses a potential, health, safety, or personal rights risk to residnets in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3