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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 277209241
Report Date: 04/09/2025
Date Signed: 04/11/2025 06:56:03 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
02/20/2025 and conducted by Evaluator Vadim Gorban
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20250220144909
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: 77DATE:
04/09/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:administrator Jesica SanchezTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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ELEVATOR NOT WORKING PROPERLY
ELEVATOR NOT SERVICED SINCE 2022
FACILITY DOES NOT HAVE SUFFICIENT STAFF TO RESPOND TO RESIDENT’S CALLS FOR ASSISTANCE
INVESTIGATION FINDINGS:
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On 04/09/2025, Licensing Program Analyst (LPA) V. Gorban conducted an unannounced subsequent complaint investigation to deliver findings on the above allegations. LPA explained the purpose Administrator Jessica Sanchez and toured the facility conducting safety checks.
During the course of the investigation, LPA conducted a facility tour, reviewed records, and conducted interviews.
The Department investigated the allegation: Elevator not working properly. It was found that on 02/16/2025, the facility elevator “broke down” with a resident inside, and became stuck between floor levels preventing residents from leaving. Based on record review and interviews, the preponderance of evidence standard has been met, therefore the allegation: Elevator not working properly is found to be SUBSTANTIATED. A deficiency is being cited in accordance with California Code of Regulations, Title 22, on the attached 9099-D.

Report continues on attached LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
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-20250220144909
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: 04/09/2025
NARRATIVE
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The Department investigated the allegation: Elevator not serviced since 2022. Record review revealed that the facility elevator was last serviced on 01/19/2021. LPA observed that the elevator permit expired on 01/19/2022. Per the Department of Industrial Relations, no elevator shall be operated without a valid, current permit. Based on observation, interviews, and records reviews, elevator next service date have not been established or recorded; the preponderance of evidence standard has been met, therefore the allegation: Elevator not serviced since 2022, is found to be SUBSTANTIATED. A deficiency is being cited in accordance with California Code of Regulations, Title 22, on the attached 9099-D.

The Department investigated the allegation: Facility does not have sufficient staff to respond to resident’s calls for assistance. It was found that on 02/16/2025, the facility elevator “broke down” with a resident inside. Record review and interviews revealed that facility staff did not respond to the elevator emergency assistant call light for approximately 30 minutes. The preponderance of evidence standard has been met, therefore the allegation: Facility does not have sufficient staff to respond to resident’s calls for assistance, is found to be SUBSTANTIATED. A deficiency is being cited in accordance with California Code of Regulations, Title 22, on the attached 9099-D.

Exit interview conducted. This report was signed on-site. A copy of this report and appeal rights were provided to Administrator.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20250220144909
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: 04/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2025
Section Cited
CCR
87303
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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.
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The facility will continue providing services through OTIS and continues follow up on permit renewal. Once received, provide POC to Licensing office by POC due date.
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This requirement was met as evidenced by: on 02/16/2025 at approximately 4:45PM a resident was trapped in the elevator when it malfunctioned for approximately 30 minutes. Based on records review elevator was not serviced since 2021, which poses potential health and safety risk to persons in care
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Type B
04/14/2025
Section Cited
CCR
87411(a)
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(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
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The Facility will appeal the citation. The retrain staff on procedures on elevator calls. Provide POC to Licensing office by POC due date
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This requirement was not met as evidenced by; when on 2/16/24, at approximately 4:45PM resident trapped in the elevator when it malfunctioned. Residents calls for assistance went unanswered for approximately 30 min, this poses potential health and safety risk ti persons in care.
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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.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3