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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601777
Report Date: 07/31/2024
Date Signed: 07/31/2024 01:10:01 PM

Document Has Been Signed on 07/31/2024 01:10 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:PARK LANE HOME IIFACILITY NUMBER:
198601777
ADMINISTRATOR/
DIRECTOR:		SHELLA MANALANGFACILITY TYPE:
735
ADDRESS:22729 NEPTUNE AVENUETELEPHONE:
(562) 595-9021
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 4CENSUS: 4DATE:
07/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:58 AM
MET WITH:Debra Estrada, Administrator TIME VISIT/
INSPECTION COMPLETED:
01:21 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 07/31/24, Licensing Program Analysts (LPAs) Hollie Enriquez and Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Debra Estrada. LPA explained the purpose of today’s visit. The facility is licensed to operate for (4) ambulatory adults ages 18 through 59. The clients are all individuals with Harbor Regional Center.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (4) client's rooms, (2) bathrooms, a living area, a dining area, a kitchen, an outside seating area, (2) staff rooms, and (1) staff bathroom.

LPA Dabuet toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 105.3 degrees F. A comfortable temperature of 71 degrees F. was maintained in the facility.

LPA Dabuet observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to clients. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. A fire extinguisher was charged. A review of the Medication Administration Records (MAR) was observed to be maintained in order.

(Evaluation Report continues LIC 809-C)
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Hollie Enriquez
LICENSING EVALUATOR SIGNATURE: DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PARK LANE HOME II
FACILITY NUMBER: 198601777
VISIT DATE: 07/31/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
During the visit, LPAs observed the facility's infection control practices. LPAs observed screening protocols for visitors, staff, and clients, and sanitizing stations in common areas and restrooms. LPA Dabuet observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA Dabuet observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on 06/07/24. The facility had operational smoke and carbon monoxide detectors in bedrooms and common areas. The facility has current liability insurance on file effective 04/06/23 - 04/06/24. The facility has a Surety Bond coverage that is current through 2026. Annual fee is due on 8/4/24 in the amount of $454. LPAs informed Adminstrator Tricia Estrevillo of amount and due date.

An audit of clients #1-#4 (C1-C4) service files and staff #1-#5 (S1-S5) personnel files revealed to be complete. An audit of the resident's P&I is maintained in order and complete. The facility has the current administrator's certification on file for Shella Manalang #6009848735 Expiration 01/17/2026 and Tricia Estrevillo #6057358735 Expiration 10/01/2024.

No deficiencies during this inspection visit.

An exit interview was conducted with Debra Estrada and a copy of the report was provided.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Hollie Enriquez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2