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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 277209241
Report Date: 05/28/2025
Date Signed: 05/30/2025 06:22:25 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
05/23/2025 and conducted by Evaluator Vadim Gorban
COMPLAINT CONTROL NUMBER: 24-AS-20250523105346
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: 75DATE:
05/28/2025
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Sales director Jonathan MonroeTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility staff are interfering with residents receiving facility notifications in their mailboxes
INVESTIGATION FINDINGS:
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On 05/08/2025, Licensing Program Analyst (LPA) V. Gorban conducted an unannounced subsequent complaint investigation to deliver findings. LPA explained the purpose of visit to sales director Jonathan Monroe. During the course of the investigation, LPA conducted a facility conducted a facility tour, interviewed residents, and reviewed records.

The Department has investigated the allegation: Facility staff are interfering with resident receiving facility notification in their mailboxes. Through interviews conducted with residents, it was discovered that facility staff interfered by removing mail correspondence, from resident mailboxes. The removed correspondence included a notice regarding an activity that was scheduled to take place on 05/19/2025. Based on interviews and records review, the preponderance of evidence standard has been met therefore the allegation: Facility staff are interfering with resident receiving facility notification in their mailboxes is SUBSTANTIATED.
Report continues onLIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
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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Control Number 24-AS-20250523105346
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: 05/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
05/30/2025
Section Cited
CCR
87468.2(a)(3)
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87468.2 (a)(3) Personal rights
(3) To be encouraged and assisted in exercising their rights as citizens and as residents of the facility. Residents shall be free from interference, coercion, discrimination, and retaliation in exercising their rights. This requirement was not met as evidenced by:
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Licensee will appeal this complaint allegations.
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Based on interviews and record review, the Licensee did not comply with section 887468.2 (a)(3) when facility failed to provide residents free from discrimination their personal rights, which is a potential health and safety risk to person’s 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: 05/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC9099 (FAS) - (06/04)
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Control Number 24-AS-20250523105346
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: 05/28/2025
NARRATIVE
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A deficiency is being cited in accordance with California Code of Regulations, Title 22, Division 6 on the attached 809D.
Exit interview conducted. Report signed on-site. A copy of this report and appeal rights were discussed and provided to the facility representative.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC9099 (FAS) - (06/04)
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