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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 277209241
Report Date: 01/21/2025
Date Signed: 01/22/2025 10:02:53 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
01/17/2025 and conducted by Evaluator Vadim Gorban
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20250117115034
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: 74DATE:
01/21/2025
UNANNOUNCEDTIME BEGAN:
11:32 AM
MET WITH:Administrator Jessica SanchezTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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The elevator was reportedly not working for an extended period, leaving residents trapped on the upper floor
Some parts of the facility do not have heat, and the facility is utilizing space heaters.
Emergency disaster plan is not sufficient
INVESTIGATION FINDINGS:
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On 01/21/2025, Manager Brenda White, Licensing Program Manager (LPM) See Moua, and Licensing Program Analyst (LPA) V. Gorban conducted an unannounced complaint commencement visit. Licensing Program personnel explained the purpose of visit to Administrator Jessica Sanchez. LPA toured the facility conducting safety checks, reviewed and received copies of facility records.

Allegation: The elevator was reportedly not working for an extended period, leaving residents trapped on the upper floor. During complaint investigation department staff interviewed administrator in regards to not working elevator. Based on information provided the facility elevator was not operational no 11/20/24 and became operational 12/13/24, during that incident no residents were stuck in elevator. Based on LPAs observations and interviews which were conducted and record review the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations number being cited on the attached LIC 9099D.
Report continues on attached LIC9099-C



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

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
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-20250117115034
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: 01/21/2025
NARRATIVE
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Allegation: Some parts of the facility do not have heat, and the facility is utilizing space heaters.
During this allegation investigation Licensing personnel interviewed facility administrator and residents. Based on observations during the visit on 1/21/25 space heaters were observed in dinning room and per regulation requirements indoor temperature has to be in required temperature parameters. The dinning room never had heating unit and the facility has always utilized space heater for heating this area. The temperature observed at 65.6 degrees F. Based on LPA observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations number being cited on the attached LIC 9099D.

Allegation: Emergency disaster plan is not sufficient. Based on administrator's interview and facility records review provided the emergency disaster plan is incomplete. The plan was not addressed transportation, staff and residents for emergency and fire drill. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations being cited on the attached LIC 9099D.

Exit interview conducted, report signed and copy of this report with appeal rights provided to Administrator for facility records.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20250117115034
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: 01/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/24/2025
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation. (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not observed as evodenced by:
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Administrator agrees to submit proof of the elevator repairs to the Department by the POC due date.
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Based on the interviews conducted and records reviewed, the elevator wasn't working properly on 11/20/24. Staff had to manually use the elevator by key for residents.
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Type B
01/24/2025
Section Cited
CCR
87303(b)(1)
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87303 Maintenance and Operation. (1) The facility shall heat rooms that residents occupy to a minimum of 68 degree F, (20 degrees C). This requirement was not observed as evidenced by: Based on observation, space heaters were used to heat the dining room.
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The Administrator agrees to submit a statement from the Fire Department regarding safety of space heaters and will submit a plan to ensure the dining room is heated and maintained at the required temperature.
Type B
01/24/2025
Section Cited
CCR
87212(b)(2)
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87212 (b) The plan shall be subject to review by the Department and shall include: (2) Plan for evacuation including... This requirement was not observed as evidenced by: the Emergency Disaster Plan was missing information regarding transportation of residents in an emergency and staff and resident's emergency drills.
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The Administrator agrees to update the Emergency Disaster Plan with the missing information and submit the plan to the Department by the POC date.
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: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3