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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 277209241
Report Date: 10/24/2024
Date Signed: 12/11/2024 11:43:58 AM

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
05/20/2024 and conducted by Evaluator Brianna Miranda
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240520161700
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: 76DATE:
10/24/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administrator Jessica SanchezTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff made significant changes to the facility's plan of operation without proper approval
INVESTIGATION FINDINGS:
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On 10/24/2024 at 3:25 PM, Licensing Program Analyst (LPA) B. Miranda conducted a subsequent visit and
met with Executive Director/ Administrator, Jessica Sanchez to deliver findings of above allegation. LPA explained the purpose of the visit with Administrator.

Allegation: Staff made significant changes to the facility's plan of operation without proper approval.

Finding: Substantiated

LIC9099-C Continued...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Brianna Miranda
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
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-20240520161700
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: 10/24/2024
NARRATIVE
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On 10/23/24 the facility file was reviewed and there was no request to change the Plan of Operation.

On 10/23/24, LPA found that the facility’s website is advertising as a “55+ independent living”
component.

On 10/24/24 LPA met with S1 and asked for a copy of Plan of Operation and a copy of admission agreement. Copy of admission agreement was provided, on page 5 it states "We own Pacifica Senior Living (the "Community"), a licensed residential care facility for the elderly located at _________, which provides residence, care and services to persons 60 years of age and older." There is an Appendix P- Addendum Declining Residence & Care Services. S1 stated they have been employed since 1/2024 and the facility has serviced the 55+ population.

LPA interviewed S2 who stated the prior owners had residence age 60+ and now there are residence age 55+.


Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of
evidence standard has been met, and the Department has determined that a significant change to the plan of
operation affecting the services of residents has been enacted without the approval of the Agency. 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 9099D. Failure to correct deficiencies by POC due date may
result in additional Civil Penalties.

Exit interview was conducted and a copy of this report LIC9099, LIC9099D, and Appeal Rights were provided to Administrator Jessica Sanchez.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Brianna Miranda
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20240520161700
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: 10/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2024
Section Cited
CCR
87208(a)
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87208 Plan of Operation
(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval.
This requirement is not met as evidenced by:
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Administrator will follow-up with upper management to have request submitted.
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Based on observations, interviews and record review, the licensee did not comply with the section cited above in by changing the plan of operation without CCLD approval which poses a potential health, safety or personal rights 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: Brianna Miranda
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3