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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 277209241
Report Date: 01/18/2024
Date Signed: 01/19/2024 12:42:56 PM


Document Has Been Signed on 01/19/2024 12:42 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:PACIFIC GROVE SENIOR LIVINGFACILITY NUMBER:
277209241
ADMINISTRATOR:HARRISON, PAULFACILITY TYPE:
741
ADDRESS:551 GIBSON AVENUETELEPHONE:
(831) 657-5200
CITY:PACIFIC GROVESTATE: CAZIP CODE:
93950
CAPACITY:150CENSUS: 73DATE:
01/18/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Executive Director, Jessica Sanchez.TIME COMPLETED:
02:48 PM
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On 1/18/24, Licensing Program Analyst (LPA) V Gorban arrived unannounced to conduct a case management inspection. LPA explained the reason for inspection and met with (ED) Jessica Sanchez.

LPA toured the facility inside and out to conduct safety checks.

CCL received an incident report on 01/11/24 facility heaters stopped working on 1/5/24. Per incident report Maintenance Director made a contact on the same day with a heating company, Enviro-Tempt to diagnose the problem. At the same, time the facility provided portable heaters to residents.
ED stated that five (5) resident rooms effected.
Facility also offered residents alternative furnished guests rooms to use meantime till central heater problem resolved.
During this visit LPA toured the facility effected section of the facility, observed residents and their rooms.

NO deficiencies were observed and cited during this visit.

Exit interview conducted, report signed and copy of this report provided for facility records.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024
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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