277209241-4-25-2023-24-AS-BCHN-CTWUZY-20230720160217

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 277209241
Report Date: 04/25/2023
Date Signed: 04/25/2023 11:58:52 AM

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
04/20/2023 and conducted by Evaluator David Ayers

COMPLAINT CONTROL NUMBER: 24-AS-20230420160908

FACILITY NAME:	PACIFIC GROVE SENIOR LIVING		FACILITY NUMBER:	277209241
ADMINISTRATOR:	FAY, SHARON		FACILITY TYPE:	741
ADDRESS:	551 GIBSON AVENUE		TELEPHONE:	(831) 657-5200
CITY:	PACIFIC GROVE	STATE: CA	ZIP CODE:	93950
CAPACITY:	150	CENSUS: 66	DATE:	04/25/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Paul Harrison - Executive Director		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Resident sustained an injury due to insufficient lighting during a power outage
Staff did not have an emergency / contingency plan in place during a county-wide power outage

INVESTIGATION FINDINGS:

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On 4/25/2023, Licensing Program Analyst(LPA) D. Ayers arrived at the facility unannounced to conduct a initial 10-day complaint inspection. LPA met with Executive Director Paul Harrison and announced the purpose of the visit.

During the visit, LPA reviewed the facility Emergency Disaster Plan, conducted interviews, and toured the facility. LPA observed the facility generator and reviewed emergency procedures with facility maintenance team and administration. During recent storms and power outages, facility staff applied their emergency disaster plan, which has been in place in its current format since November 2022. Based off of interviews, no residents were injured as a direct result of poor lighting. The allegations are Unsubstantiated. No deficiencies were cited during the inspection. A copy of the report was provided and exit interview conducted with Executive Director.

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: 04/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

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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