277209241-6-20-2023-24-AS-SPIY-CX8RMA-20231103130823

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 277209241
Report Date: 06/10/2023
Date Signed: 06/20/2023 11:54:19 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/08/2023 and conducted by Evaluator Shawna Doucette

COMPLAINT CONTROL NUMBER: 24-AS-20230608152150

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: 64	DATE:	06/10/2023
		UNANNOUNCED	TIME BEGAN:	09:06 AM
MET WITH:	Administrator Paul Harrison and Activities Director Lucy Clem		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility is without hot water.
Facility is not providing cleaning services for residents apartments.
Staff are sleeping during shifts.
Residents are paying for services that are not being rendered.
Facility is threatening to evict residents in care.
Facility staff are not communicating with residents.

INVESTIGATION FINDINGS:

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The reason for the amendment is to add Department language.

Licensing Program Analyst (LPA) Shawna Doucette arrived unannounced to conduct a complaint investigation. LPA explained reason for inspection and was granted entry by Staff Christiana Libhart. LPA met with Administrator Paul Harrison and Activities Director Lucy Clem.

Based on interviews, it was found facility was without hot water in one of the wings, however facility offered residents to be able to have hot showers in another wing that had hot water. Facility contacted maintenance for repair and the hot water issue was repaired.

Based on regluations, Facilities are not required to provide a licensed nurse in the facility.

Based on interviews and review of staff schedule for April 21, 2023, although staff was found lying down, staff was on a break and there were other staff available to assist residents in care.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna Doucette	TELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/08/2023 and conducted by Evaluator Shawna Doucette

COMPLAINT CONTROL NUMBER: 24-AS-20230608152150

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: 64	DATE:	06/10/2023
		UNANNOUNCED	TIME BEGAN:	09:06 AM
MET WITH:	Administrator Paul Harrison and Activities Director Lucy Clem		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility is without a nurse.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Shawna Doucette arrived unannounced to conduct a complaint investigation. LPA explained reason for inspection and was granted entry by Staff Christiana Libhart. LPA met with Administrator Paul Harrison and Activities Director Lucy Clem.

This agency has investigated the complaint alleging, Facility is without a nurse. Based on regluations, facilities are not required to provide a licensed nurse in the facility.We have found that the complaint was UNFOUNDED, which means the the allegation could not have happened, and/or is without reasonable basis, therefore we have dismissed the complaint.

An exit interview was conducted with Activities Director Lucy Clem and a copy of this report was provided.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna Doucette	TELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 24-AS-20230608152150

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: PACIFIC GROVE SENIOR LIVING	FACILITY NUMBER: 277209241
	VISIT DATE: 06/10/2023

NARRATIVE

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Based on interviews and observation, apartments are being cleaned once a week. LPA observed Rm 237,226,236,242 and 335. Rooms were observed to be clean.

Based on interviews it was undetermined whether or not residents are paying for services not rendered.

Based on interviews of staff and residents, there are no residents at this time that are being threatened to be evicted.

Based on interviews of staff and residents, it was undetermined if staff are not communicating with residents.

Based on interviews and observation, it is undertimined if above allegations occurred. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted. A copy of this report was given to Activities Director Lucy Clem, whose signature confirms receipt of this report.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna Doucette	TELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2023

LIC9099 (FAS) - (06/04)

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