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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 277209241
Report Date: 02/06/2023
Date Signed: 02/07/2023 06:37:17 AM


Document Has Been Signed on 02/07/2023 06:37 AM - 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:
02/06/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:11 AM
MET WITH:Beau AyersTIME COMPLETED:
03:42 PM
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On 02/06/22, 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 facility LPA observed residents to be having lunch in the dining room, others participating in a language class in the Fireside Lounge, and other relaxing in their rooms. Currently, facility has 4 residents receiving hospice services. Facility observed to have an adequate supply of food available for the residents in care. Facility continues to have food deliveries 3-4 days per week for both perishable and non-perishable food.

LPA Medina met with and interviewed residents during facility visit.

LPA met with Beau Ayers, Regional Vice President of Operations to conduct exit interview. LPA received copy of memos to residents, family and staff dated January 2023, facility menu for the week beginning 2/05/22, a news letter and activities calendar both dated February 2023, 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: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2023
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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