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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 277209241
Report Date: 12/15/2022
Date Signed: 12/15/2022 12:47:21 PM


Document Has Been Signed on 12/15/2022 12:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



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: 61DATE:
12/15/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:01 AM
MET WITH:Paul HarrisonTIME COMPLETED:
12:57 PM
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On 12/15/22, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Case Management visit. COVID-19 screening protocols continued to be in place, LPA self screened upon entrance. All staff observed to be wearing face mask throughout facility.

LPA Medina toured kitchen with Gilbert Chavez, Executive Chef. LPA observed a 2-day supply of perishable food and a 7-day supply of non-perishable food available on site. Facility receives perishable food deliveries 2-3 times per week and non-perishable food is received 2 times per week. LPA Medina received a copy of the menu for the week beginning 12/11/22.

LPA Medina toured facility with Joey Garcia, Director of Operations. LPA observed residents to be having lunch in the dining room and others enjoying a Holiday program in the Fireside Lounge. Currently, facility has 2 residents receiving hospice services.

LPA met with Paul Harrison, Executive Director to conduct exit interview. LPA received copy of memo to residents, family and staff dated 12/05/22, LIC 500 and LIC 9020 during facility visit.

No deficiencies observed or cited during visit.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022
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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