<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 277209241
Report Date: 05/30/2025
Date Signed: 05/30/2025 04:51:03 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 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
05/29/2025 and conducted by Evaluator Jacques Leffall
COMPLAINT CONTROL NUMBER: 24-AS-20250529135712
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: 76DATE:
05/30/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administator: Jessica SanchezTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Unlawful Eviction

Facility changed its Plan of Operation without Department Approval
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 5/30/25 at 2:00 pm Licensing Program Analyst (LPA) J. Leffall conducted an initial complaint visit to open and to deliver findings on above allegations. LPA met with Administrator (A1) Jessica Sanchez.

The Department conducted interviews and reviewed records. The records reviewed included the resident’s Admission Agreement and Eviction Notice that was issued to the residents. The Eviction Notice was not submitted to the Department and there was no proof that it was submitted. The facility is operating under a plan that was not approved by the Department.

The above allegations are Substantiated according to Title 22 Regulations and are cited on the attached 9099-D.

An exit interview was conducted and Appeal rights were provided.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Jacques Leffall
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
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 2
Control Number 24-AS-20250529135712
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PACIFIC GROVE SENIOR LIVING
FACILITY NUMBER: 277209241
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/13/2025
Section Cited
CCR
87224(f)
1
2
3
4
5
6
7
87224

(f) Eviction Procedures - A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement was not met as evidence by:

Based on records reviewed and interviews conducted, the facility failed to notify the Department of the eviction, which poses a potential health, safety, and personal rights to the residents in care.
1
2
3
4
5
6
7
Licensee agrees will submit 5 day notice to CCLD upon eviction notices to residents.
8
9
10
11
12
13
14
8
9
10
11
12
13
14
Type B
06/13/2025
Section Cited
CCR
87208(a)
1
2
3
4
5
6
7
87208

(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval.
This requirement is not met as evidenced by:

Based on observations, interviews and record review, the licensee did not comply with the section cited above in by changing the plan of operation without CCLD approval which poses a potential health, safety or personal rights risk to persons in care.
1
2
3
4
5
6
7
Licensee provided Plan Of Operations and will appeal citation issued.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: See Moua
LICENSING EVALUATOR NAME: Jacques Leffall
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2