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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 277209241
Report Date: 02/25/2025
Date Signed: 02/25/2025 12:07:01 PM

Document Has Been Signed on 02/25/2025 12:07 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
FRESNO RO, 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: 79DATE:
02/25/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Melissa ArangoTIME VISIT/
INSPECTION COMPLETED:
12:17 PM
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On 2/25/2025, Licensing Program Analyst (LPA) M. Medina arrived to conduct an unannounced Case Management visit. LPA arrived, introduced self, stated purpose of visit, and allowed entrance into facility. Executive Director, Jessica Sanchez was unavailable during today's visit. LPA met with Melissa Arango, Business Office Manager to conduct visit and facility tour.

LPA conducted visit to follow up on two (2) self reported incidents that both occurred on 2/16/25, the incidents involved Resident 1 (R1) and Resident 2 (R2). Both incidents were reviewed by this Department on 2/24/25. LPA also toured facility to verify that contractors who were observed to be living on site during a visit conducted on 2/21/25 by LPA Gorban were no longer on the premises.

For incident involving R1, LPA gathered information and obtained copies of R1's physician report and Identification and Emergency Information sheet (LIC 601).

For incident involving R2, LPA toured facility, used elevators to tour facility, tested emergency call button in elevator, and gathered documents available for elevator repair. Per telephone conversation with Executive Director (ED) there is currently no other documentation available regarding repair. If additional information is needed by Department, ED will request from OTIS Elevator Company which serviced elevator.

LPA toured Independent Living West Wing and observed room where contractors were residing to be vacant, LPA observed items that were present which indicated the unit was at one time occupied. No personal belongings were observed in the unit.

No deficiencies cited during this Case Management visit, deficiencies if observed may be cited at a later date.

Exit interview conducted. A copy of this report provided to facility for their records
SUPERVISORS NAME: Alexandria Walton
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2025
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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