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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 277209241
Report Date: 10/15/2024
Date Signed: 10/16/2024 01:37:37 PM

Substantiated


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
08/22/2024 and conducted by Evaluator Vadim Gorban
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240822133921
FACILITY NAME:PACIFIC GROVE SENIOR LIVINGFACILITY NUMBER:
277209241
ADMINISTRATOR:JESSICA SANCHEZFACILITY TYPE:
741
ADDRESS:551 GIBSON AVENUETELEPHONE:
(831) 657-5200
CITY:PACIFIC GROVESTATE: CAZIP CODE:
93950
CAPACITY:150CENSUS: 75DATE:
10/15/2024
UNANNOUNCEDTIME BEGAN:
10:59 AM
MET WITH:Administrator Jessica SanchezTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff unlawfully evicted a resident
Staff is not abiding to admission agreement
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) V Gorban arrived at the facility unannounced to conduct a subsequent visit and met with Administrator Jessica Sanchez to deliver findings of above allegation. LPA explained the purpose of the visit with administrstor.

During the course of the investigation, the Department conducted interviews and reviewed records.

With regards to the allegation, Staff unlawfully evicted a resident. The Provider issued a three-day eviction notice to the resident on August 16,2024. The department has obtained a copy of the notice. Based on the interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099-D.

Report continues on attached LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 24-AS-20240822133921
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 277209241
VISIT DATE: 10/15/2024
NARRATIVE
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With regards to the allegation, Staff is not abiding to admission agreement. The Provider did provide a Three-Day Notice to Pay or Quit to the resident on August 16, 2024. The Care and Residence Agreement and the Continuing Care Contract Statutes both provide for termination of an agreement upon ninety (90) day’s written notice to resident with good and sufficient cause as required by Health and Safety Code section 1788(a)(31). Based on the interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Exit interview conducted, administrator refused to sign a report. Appeal rights provided to Administrator for facility records.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20240822133921
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 277209241
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/17/2024
Section Cited
CCR
87224(a)(1)
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87224 (a)(1) Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5). (1) Nonpayment of the rate for basic services within ten days of the due date. This requirement was not observed as evidenced by:
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Refused to offer plan of correction.
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Based on review of record , interviews and documentation obtained during the investigation, the facility administrator did not provide the resident with the required 30 day written notice of eviction. The facility failed to follow title 22 regulation in regards to Eviction procedures which poses potential health and safety risk to persons in care.
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Type B
10/18/2024
Section Cited
HSC
1788(a)(31)
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H&S §1788 (a)(31) The Care and Residence Agreement and the Continuing Care Contract Statutes both provide for termination of an agreement upon ninety (90) day’s written notice to resident with good and sufficient cause as required by Health and Safety Code section 1788(a)(31). This requirement was observed as evidenced by:
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Refused to offer plan of correction.
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Based on review of records, interviews and documents obtained during the investigation, the provider issued the resident a three-Day Notice to Pay or Quit to the resident on August 16, 2024, which poses potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3