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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 277209241
Report Date: 12/04/2024
Date Signed: 12/05/2024 07:57:32 AM

Unfounded


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
11/26/2024 and conducted by Evaluator Vadim Gorban
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20241126141511
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: 73DATE:
12/04/2024
UNANNOUNCEDTIME BEGAN:
12:17 PM
MET WITH:Administrator Jessica Sanchez TIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not adhere to resident's Admission Agreement.
Licensee is not ensuring that facility is free from mold.
Facility is in disrepair.
Staff did not accord dignity to resident in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/04/2024, Licensing Program Analyst (LPA) V. Gorban conducted an unannounced follow up complaint visit. LPA explained the purpose of visit to Administrator Jessica Sanchez. LPA toured the facility conducting safety checks, reviewed and received copies of facility records.

Allegations: Facility did not adhere to resident's Admission Agreement. Licensee is not ensuring that facility is free from mold. Facility is in disrepair. Staff did not accord dignity to resident in care.
During complaint investigation department reviewed facility files and interview administrator. Based on information provided the resident (R1) is not under Licensing supervision and jurisdiction. Based on these findings, the department have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview conducted, report signed and copy of this report provided to Administrator for facility records.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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