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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 277209241
Report Date: 11/12/2024
Date Signed: 12/03/2024 05:28:50 PM

Document Has Been Signed on 12/03/2024 05:28 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: 75DATE:
11/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Administrator Jessica SanchezTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
NARRATIVE
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On 11/12/2024, Licensing Program Analyst (LPA) V Gorban arrived at the facility unannounced to conduct Required Annual Inspection. LPA met with Administrator (AD) Jessica Sanchez, certification number 6072416740 and expiration date 10/01/2026. LPA conducted tour inside and out of facility with AD. Residents observed at the facility during lunch time.

The facility was observed to be at a comfortable temperature of 77 degrees, clean, in good repair, and no passageway obstructions or fire hazards observed. Fire extinguisher was observed with a service date of 05/13/2024

Dining this visit Kitchen and dinning room were toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in freezer, refrigerator, and pantry. Food is delivered twice a week on Tuesdays and Thursdays. Refrigerator temperature was maintained at 42.0-degree F. and freezer was maintained at -5-degree F.

LPA toured resident bedrooms. Residents' rooms were toured and observed with adequately furnished with bed, dresser, and adequate lighting. Hot water temperature tested at 110.6 degrees F. LPA observed securely fastened grab bar and non-skid mat in shower area.

Medications were stored in a locked medication room in a medication cart. Medication records tracked by QuickMar. Medications records were reviewed. First Aid Kit was stored in medication room and observed with all required items. Adequate PPE supplies was observed. LPA toured laundry room and observed chemicals were stored and locked for staff use only.

Facility courtyard was toured and observed to be free from debris. There was outdoor seating available for the residents.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/12/2024
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A sample of residents’ file was reviewed to have updated emergency contact, Admission agreement, Needs and Services Plan and Pre-Appraisal Plan. A sample of staff files were reviewed. Staff files were observed to have current First Aid/CPR, Health screening, and Personnel record. Staff are fingerprinted clear and associated to the facility.

Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below:

Residential Care Facility for the Elderly (RCFE):


· LIC 308 Designation of Facility Responsibility
· LIC 309 Administrative Organization
Plan of Operations
· LIC 500 Personnel Report
Liability Insurance
· LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly
· LIC 9020 Register of Facility Clients/Residents


Please submit the above forms/information to Fresno CCL by: 11/15/2024

As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed.


An exit interview was conducted with the ED. Deficiency attached on LIC809-D

A copy of this report was given to the ED, whose signature on this form confirm receipt of these reports.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/03/2024 05:28 PM - It Cannot Be Edited


Created By: Vadim Gorban On 11/12/2024 at 04:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PACIFIC GROVE SENIOR LIVING
FACILITY NUMBER: 277209241

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)
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. The plan and related materials shall contain the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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Administrator will provide plan on develop / create a plan of operations by POC due date
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Brenda Chan
LICENSING EVALUATOR NAME:Vadim Gorban
LICENSING EVALUATOR SIGNATURE:
DATE: 11/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2024


LIC809 (FAS) - (06/04)
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