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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 277209241
Report Date: 10/28/2024
Date Signed: 10/28/2024 08:49:29 PM

Document Has Been Signed on 10/28/2024 08:49 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/
DIRECTOR:		JESSICA SANCHEZFACILITY TYPE:
741
ADDRESS:551 GIBSON AVENUETELEPHONE:
(831) 657-5200
CITY:PACIFIC GROVESTATE: CAZIP CODE:
93950
CAPACITY: 150CENSUS: 72DATE:
10/28/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Business Office Director, Melissa ArangoTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On 10/28/2024, Licensing Program Analyst (LPA) V Gorban visited the facility to follow up on Plan Of Correction, additional information and to observe facility water temperature regulations status.

During this visit LPA toured the facility performing safety checks, checked facility temperature status and interview resident. LPA requested facility files and interviewed facility staff.

No deficiency were cited during this visit.

Exit interview conducted, report signed and copy provided to Business Office Director for facility records.


SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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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