Inspection Reports for Pacific Grove Senior Living

The inspection was an unannounced complaint investigation triggered by an allegation that residents were exposed to harmful chemicals.

The investigation included a facility tour, interviews, and record reviews. The allegation was found to be unsubstantiated as there was no preponderance of evidence to prove the alleged violation occurred, and no harmful smells or paint odors were observed during the visit.

The complaint alleged that residents were exposed to harmful chemicals. The allegation was investigated and found to be unsubstantiated.

Licensing Program Analyst conducted a Health and Safety check in response to a news article published on 08/20/2025 regarding a staff member at the Skilled Nursing Facility inside the facility being arrested on felony charges of sexual assault.

The Skilled Nursing Facility was confirmed to be a separate entity with a different main entrance, and there was no interaction between Skilled Nursing staff and the residents of the facility. It was confirmed that the individual arrested had never worked at or had contact with residents of the facility.

The inspection was an unannounced case management visit conducted due to an incident on April 20, 2025, when the fire department responded to a fire alarm at the facility.

The Licensing Program Analyst observed that staff member S1 had missing training/education related to fire response and disaster response, which poses a potential health and safety risk to residents. A deficiency was cited per Title 22 and a plan of correction was developed by the administrator.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2025-05-09 regarding allegations about the facility's administration and staffing during meal times.

The investigation found that when the Administrator is not present, a designated substitute manages the facility, and there are sufficient staff members available during meal times. Both allegations were unsubstantiated and no deficiencies were issued.

The complaint alleged that the licensee did not ensure a qualified administrator was present and did not have enough staff during meal times. Both allegations were investigated and found to be unsubstantiated.

The inspection visit was an unannounced complaint investigation triggered by a complaint received on 2025-03-27 alleging that staff were not adhering to residents' contracts.

The investigation included a facility tour, interviews, and record reviews. The allegation that staff were not adhering to residents' contracts was found to be unsubstantiated due to lack of preponderance of evidence. No deficiencies were issued.

The complaint alleged that staff were not adhering to residents' contracts. The allegation was investigated and found to be unsubstantiated.

An unannounced complaint investigation was conducted based on a complaint received on 2025-04-18 regarding allegations including the facility not employing a qualified food service consultant and failure to conduct disaster drills as required.

The allegation that the facility does not employ a qualified food service consultant was found to be unfounded. However, the allegation that disaster drills were not being conducted as required was substantiated, with the facility failing to conduct recent emergency disaster drills or maintain records, posing a potential health and safety risk.

The complaint investigation was triggered by allegations received on 2025-04-18. The allegation regarding lack of a qualified food service consultant was found to be unfounded. The allegation regarding failure to conduct disaster drills quarterly on each shift was substantiated based on the preponderance of evidence standard.

The inspection was an unannounced complaint investigation visit conducted due to an allegation that facility staff interfered with residents receiving notification and watching an upcoming event.

The investigation substantiated the allegation that facility staff interfered with residents receiving memos in their mailboxes, although residents were allowed to watch the upcoming event. A deficiency was cited and a civil penalty assessed.

The complaint was substantiated based on interviews and observations. The allegation was that facility staff interfered with residents receiving notification and watching an upcoming event. The preponderance of evidence standard was met and a deficiency was cited with a civil penalty assessed.

An unannounced complaint investigation visit was conducted in response to allegations including unlawful eviction and unauthorized changes to the facility's Plan of Operation.

The investigation substantiated that the facility failed to notify the Department of an eviction and operated under a Plan of Operation that was not approved by the Department, violating Title 22 Regulations.

The complaint investigation was substantiated based on evidence that the facility unlawfully evicted residents without notifying the Department and changed its Plan of Operation without approval.

The inspection was an unannounced complaint investigation triggered by an allegation that facility staff were interfering with residents receiving facility notifications in their mailboxes.

The investigation substantiated that facility staff interfered by removing mail correspondence from resident mailboxes, including a notice about an activity scheduled for 05/19/2025. This was found to be a violation of residents' personal rights under CCR 87468.2(a)(3).

The complaint was substantiated based on interviews and records review, confirming that facility staff removed mail correspondence from resident mailboxes, interfering with residents receiving facility notifications.

An unannounced complaint investigation was conducted following multiple allegations received on 2025-02-20 regarding garbage not being picked up, inadequate emergency lighting, plumbing issues, construction disturbances, and failure to conduct quarterly fire drills.

The investigation substantiated several allegations including garbage accumulation due to nonpayment of waste services, non-functioning emergency lighting, plumbing issues, failure to conduct quarterly fire drills, and construction disturbances involving early work hours and loud music. Other allegations such as mold presence, delayed repairs due to staffing, and improper rate increases were found unsubstantiated.

The complaint investigation was substantiated for allegations of garbage not being picked up, inadequate emergency lighting, plumbing issues, failure to conduct quarterly fire drills, and construction disturbances. Allegations of mold, delayed repairs due to staffing, and improper rate increases were unsubstantiated.

The visit was conducted for Case Management - Health Checks to assess health and safety conditions of clients in care at the facility.

The assisted living section's call light system was found not to operate as required, with four out of nine residents unable to utilize the call system, posing a potential health and safety risk.

The inspection was an unannounced complaint investigation conducted in response to allegations received on 2025-02-20 regarding elevator malfunction, lack of elevator servicing since 2022, and insufficient staff to respond to resident calls for assistance.

The investigation substantiated all three allegations: the elevator broke down trapping a resident inside on 2025-02-16; the elevator had not been serviced since 2021 and the permit expired in 2022; and staff did not respond to the elevator emergency call light for approximately 30 minutes. Deficiencies were cited under California Code of Regulations, Title 22.

The complaint investigation was substantiated based on evidence that the elevator malfunctioned trapping a resident, the elevator was not serviced since 2021 with an expired permit, and staff failed to respond timely to resident calls for assistance during the elevator emergency.

The visit was an unannounced case management inspection conducted to perform health and safety checks and provide an amended report.

During the visit, the Licensing Program Analyst conducted a facility tour, reviewed emergency lighting, and observed residents in care. No deficiencies were cited during this visit.

The visit was an unannounced Case Management visit to follow up on two self-reported incidents involving residents and to verify that contractors previously observed living on site were no longer present.

No deficiencies were cited during this Case Management visit. The Licensing Program Analyst gathered information related to two incidents and toured the facility, including testing the elevator emergency call button and verifying contractor residency status.

The inspection was an unannounced complaint investigation visit triggered by allegations including a non-working elevator, insufficient heating in parts of the facility, and an incomplete emergency disaster plan.

The investigation substantiated all three allegations: the elevator was non-operational from 11/20/24 to 12/13/24 with no residents trapped; space heaters were used in the dining room which lacked a heating unit, with observed temperature below required minimum; and the emergency disaster plan was incomplete, missing transportation and emergency drill details.

The complaint investigation was substantiated based on the preponderance of evidence standard for all allegations: elevator malfunction, insufficient heating, and incomplete emergency disaster plan.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-12-26 alleging that staff did not prevent a resident from creating a hostile environment for other residents in care.

The investigation found that the resident involved was not under Licensing supervision and jurisdiction. Based on this, the complaint was determined to be unfounded, meaning the allegation was false, could not have happened, or was without reasonable basis.

Complaint was found to be unfounded after review of facility files and interview with the administrator. The resident involved was not under Licensing supervision and jurisdiction.

The visit was conducted to amend the original report, collect the original report, and provide a copy of the amended report.

No tour of the facility was completed as the sole purpose of the visit was to provide the amended report. An exit interview was conducted, the original report was collected, and a copy of the amended report was emailed to the Administrator.

The inspection was an unannounced complaint investigation visit triggered by a complaint alleging that staff do not ensure the facility is free from pests.

The investigation found that the facility had a problem with vermin but had increased pest control services to twice a week to address the issue. The allegation was unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that staff did not ensure the facility was free from pests. The allegation was unsubstantiated after investigation.

The inspection was an unannounced complaint investigation visit triggered by allegations that the facility retaliates against residents for complaints made and serves food that is not of good quality.

The investigation found no preponderance of evidence to substantiate the allegations. Observations and interviews indicated no concerns from residents regarding retaliation, and food quality was found to be satisfactory with no expired food observed.

The complaint investigation was unsubstantiated as there was insufficient evidence to prove the alleged violations occurred.

The inspection was an unannounced complaint investigation visit triggered by allegations that the facility heater and elevator were in disrepair and that staff were not available to assist residents.

The investigation found the complaint to be unfounded, meaning the allegations were false, could not have happened, or were without a reasonable basis. The Licensing Program Analyst toured the facility, conducted safety checks, reviewed records, and interviewed the administrator.

The complaint was investigated and found to be unfounded. Allegations included facility heater disrepair, elevator disrepair, and staff unavailability to assist residents. The resident involved was not under Licensing supervision and jurisdiction.

The inspection was an unannounced complaint investigation visit triggered by a complaint alleging that staff were not providing a comfortable environment for residents.

The investigation found that the resident involved was not under Licensing supervision and jurisdiction, and the complaint was determined to be unfounded, meaning the allegation was false or without reasonable basis.

Complaint was found to be unfounded after investigation; the allegation that staff were not providing a comfortable environment for residents was false or without reasonable basis.

The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2024-11-26 regarding allegations of non-adherence to resident's Admission Agreement, presence of mold, facility disrepair, and staff not according dignity to residents.

The investigation found that the resident in question was not under Licensing supervision and jurisdiction, and the complaint was determined to be unfounded, meaning the allegations were false or without reasonable basis.

The complaint was investigated and found to be unfounded.

The inspection was an unannounced required annual inspection conducted to evaluate compliance with licensing regulations for the Pacific Grove Senior Living Facility.

The facility was found to be clean, in good repair, with no fire hazards or passageway obstructions. Food storage and temperatures were adequate, resident rooms were properly furnished, and medications were securely stored. A deficiency was cited for failure to maintain a current written plan of operation.

The visit was conducted to follow up on the Plan of Correction, gather additional information, and observe the facility's water temperature regulations status.

During the visit, the Licensing Program Analyst toured the facility, performed safety checks, checked water temperature status, interviewed a resident and staff, and found no deficiencies cited.

The inspection was an unannounced complaint investigation visit triggered by an allegation that staff made significant changes to the facility's plan of operation without proper approval.

The allegation was substantiated. The investigation found that the facility changed its plan of operation affecting services to residents without approval from the licensing agency, posing potential health, safety, or personal rights risks.

The complaint alleged that staff made significant changes to the facility's plan of operation without proper approval. The allegation was substantiated based on observations, interviews, and record reviews.

The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility had no hot water or heat for the residents.

The investigation found that residents did not have access to hot water on 10/14, 10/15, and 10/17 due to boiler issues causing intermittent lack of hot water in the South Wing Building. The allegation was substantiated based on observations, interviews, and records review.

The complaint was substantiated. The allegation that the facility had no hot water or heat for residents was confirmed based on evidence collected during the investigation.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-08-22 regarding unlawful eviction of a resident and staff not abiding by the admission agreement.

The investigation substantiated both allegations: staff unlawfully evicted a resident by issuing a three-day eviction notice without providing the required 30-day written notice, violating eviction procedures and admission agreement terms. The facility failed to comply with Title 22 regulations and Health and Safety Code section 1788(a)(31), posing potential health and safety risks to residents.

The complaint investigation was substantiated based on the preponderance of evidence standard. The allegations included unlawful eviction and non-compliance with the admission agreement. The administrator refused to sign the report, but appeal rights were provided.

An unannounced complaint investigation was conducted in response to allegations that the facility was without hot water and heat.

The investigation found that the facility's boiler igniter was malfunctioning, causing intermittent lack of heat and hot water in the south wing since 05/25/2024. Water temperatures measured were below required levels, and the allegations were substantiated.

The complaint was substantiated based on interviews, observations, and records review. The facility was found to have intermittent heating and hot water issues in the south wing since 05/25/2024.

An unannounced complaint investigation was conducted in response to an allegation that a resident's ceiling was leaking water.

The investigation found that the ceiling leak had been repaired by facility staff prior to the inspection, with no active leaks observed at the time. The allegations were unsubstantiated and no deficiencies were cited.

The complaint was unsubstantiated as there was not a preponderance of evidence to prove the alleged violations did or did not occur.

An unannounced complaint investigation was conducted following a complaint received on 2023-09-07 regarding staff assistance with medications, mobility, and diet plan adherence for a resident.

The investigation found all allegations to be unsubstantiated after inspection, interviews, and record reviews. No deficiencies were cited.

The complaint involved allegations that staff did not assist a resident with obtaining prescriptions for OTC medications, did not assist with mobility issues, and did not follow the resident's modified diet plan. All allegations were found unsubstantiated.

The visit was a Case Management - Incident visit conducted to follow up on an incident involving Staff 1 and Resident 1, including collection of related documents and evidence.

No deficiencies were cited during this visit per Title 22 Regulation. The Licensing Program Analyst collected various documents and information related to the incident and conducted an exit interview with the Executive Director.

An unannounced complaint investigation was conducted following a complaint received on 08/24/2023 regarding allegations that facility staff were not providing services agreed to in the Admissions Agreement and were not adhering to food service requirements.

The investigation found the allegations to be unsubstantiated. Facility staff were providing the agreed services including 24-hour emergency response with nurse oversight, and food service met regulatory requirements with adequate quantity, quality, and proper storage.

The complaint investigation was unsubstantiated as there was no preponderance of evidence to prove the alleged violations occurred.

An unannounced complaint investigation was conducted in response to a complaint received on 2023-12-06 alleging that the facility was without running water.

The investigation found that although the facility was without running water in the independent cottages for approximately 10 hours, the issue was promptly fixed and residents in the assisted living section were not affected. The allegations were determined to be unsubstantiated due to insufficient evidence.

The complaint alleged the facility was without running water. The investigation determined the allegation to be unsubstantiated.

The inspection was an unannounced case management visit focused on health checks following an incident report about facility heaters stopping working.

The Licensing Program Analyst toured the facility and conducted safety checks. No deficiencies were observed or cited during the visit.

The inspection was an unannounced required annual inspection conducted by Licensing Program Analyst D. Ayers to evaluate compliance with licensing requirements.

The facility was found to be clean, well-maintained, and compliant with regulations. Resident rooms and bathrooms met requirements, food storage was proper, and staff files and emergency plans were reviewed. No deficiencies were cited during the inspection.

An unannounced complaint investigation was conducted following a complaint received on 2023-05-25 regarding facility disrepair.

The investigation substantiated that the facility was in disrepair due to an active water leak in the underground resident parking garage that created a large puddle not marked or blocked off, presenting a potential health and safety risk to residents. The leak was repaired by 2023-07-13 and the deficiency was cleared.

The complaint was substantiated. The facility was found to have an active leak from water pipes running along the ceiling of the underground resident parking garage, causing a puddle approximately 20 feet by 10 feet and over an inch deep, which was not marked or blocked off at the time of inspection.

An unannounced complaint investigation was conducted in response to a complaint received on 07/21/2023 regarding allegations of staff negligence and mistreatment of residents.

The investigation found all allegations unsubstantiated after facility inspection, interviews, and record reviews. No immediate or potential health and safety risks were identified during the visit.

The complaint included allegations that a resident developed pressure sores due to staff negligence, sustained skin lacerations due to staff negligence, was handled roughly causing bruising, and that staff spoke inappropriately to the resident. All allegations were determined to be unsubstantiated due to lack of sufficient evidence.

The visit was an unannounced case management inspection to amend a complaint and conduct a case management regarding stairway lighting reported during a prior complaint investigation.

The issue regarding stairway lighting was already investigated and findings were delivered on a previous complaint. The facility is following the emergency disaster plan.

The visit was related to amending a complaint about stairway lighting. The issue was previously investigated and findings were delivered on complaint 24-AS-20230523092746.

An unannounced complaint investigation was conducted in response to multiple allegations including lack of hot water, inadequate cleaning services, staff sleeping during shifts, residents paying for unrendered services, eviction threats, and poor staff communication.

The investigation found the facility was temporarily without hot water in one wing but provided alternatives and repaired the issue. Staff were observed on break, not sleeping during shifts. Cleaning services were provided weekly. Other allegations such as eviction threats, payment for unrendered services, and staff communication were undetermined due to insufficient evidence. The complaint was ultimately unsubstantiated.

The complaint was unsubstantiated. Allegations included lack of hot water, inadequate cleaning, staff sleeping on duty, residents paying for services not rendered, eviction threats, and poor communication. Some allegations were found untrue or undetermined due to lack of evidence.

An unannounced complaint investigation was conducted in response to an allegation that emergency lights in the stairwell were in disrepair.

The allegations were found to be unsubstantiated. No deficiencies were cited during the inspection. The facility's emergency disaster plan and emergency lighting procedures were reviewed and found to be adequate.

The complaint investigation was unsubstantiated as no violations were found related to the emergency lights in the stairwell.

The inspection was an unannounced complaint investigation visit triggered by allegations related to resident injury due to insufficient lighting during a power outage and lack of an emergency plan during a county-wide power outage.

The investigation found that the facility had an emergency disaster plan in place since November 2022, which was applied during recent storms and power outages. No residents were injured as a direct result of poor lighting, and the allegations were unsubstantiated. No deficiencies were cited.

The complaint was unsubstantiated after investigation. Allegations included a resident injury due to insufficient lighting during a power outage and lack of an emergency/contingency plan during a county-wide power outage.

An unannounced Case Management visit was conducted to assess health checks and compliance with COVID-19 screening protocols.

The facility was observed to have residents dining and relaxing, with one resident receiving hospice care. The facility had an adequate food supply and ongoing food deliveries. The dining area was undergoing remodeling without prior notice to the licensing agency.

An unannounced Case Management visit was conducted to assess health checks and compliance with COVID-19 screening protocols at the facility.

No deficiencies were observed or cited during the visit. The facility was found to have adequate food supplies, residents engaged in activities, and staff following COVID-19 protocols.

An unannounced Case Management visit was conducted to assess health checks and compliance with COVID-19 screening protocols.

No deficiencies were observed or cited during the visit. The facility maintained adequate food supplies and residents were observed participating in activities and meals.

The visit was conducted as part of a change of ownership application and pre-licensing readiness evaluation for the Residential Care Facility for the Elderly with Continuing Care Retirement Community.

The applicant and administrator participated in a COMP II telephone interview to verify identification and confirm understanding of California Code Title 22 regulations, including facility operation, admission policies, staffing, health conditions, emergency preparedness, complaints, and reporting.

An unannounced pre-licensing inspection was conducted due to the facility applying for a license under change of ownership.

The facility appeared clean and in good repair with no deficiencies noted. All required safety equipment and postings were observed, and the facility was adequately stocked and equipped for resident care.

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