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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 277209241
Report Date: 02/22/2023
Date Signed: 02/22/2023 03:28:31 PM


Document Has Been Signed on 02/22/2023 03:28 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: 56DATE:
02/22/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Tracy Lundy - Office ManagerTIME COMPLETED:
03:45 PM
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On 02/22/23, Licensing Program Analyst's (LPAs) M. Medina and D. Ayers conducted an unannounced Case Management visit. COVID-19 screening protocols continued to be in place, LPA's self screened upon entrance. All staff observed to be wearing face mask throughout facility.

LPA's toured facility and observed residents to be having lunch in the dining room and other relaxing in their rooms. Currently, facility has 1 resident 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.

During the visit, LPA's observed that facility dining area was in the process of being remodeled. As of this date, CCLD has not received any notice of plans to alter or remodel the facility.

LPA's met with and interviewed residents during facility visit.

LPA's met with Tracy Lundy to conduct exit interview.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: David AyersTELEPHONE: (559) 408-4163
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023
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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