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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602990
Report Date: 03/28/2022
Date Signed: 03/29/2022 11:54:32 AM

Document Has Been Signed on 03/29/2022 11:54 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:PARK LANE HOME 1FACILITY NUMBER:
198602990
ADMINISTRATOR:SHELLA MANALANGFACILITY TYPE:
735
ADDRESS:3145 PARK LANETELEPHONE:
(562) 426-9616
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY: 4CENSUS: 4DATE:
03/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Debra EstradaTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Jeremiah Randle conducted an unannounced Annual inspection visit and infection control inspection to the above facility. LPA was met by Debra Estrada, Administrator and the purpose of today’s visit was explained.There are currently (4) Regional Center consumers in placement. All (4) clients are ambulatory. The facility is a single-story structure located in a residential neighborhood. It consists of the following: 5 bedrooms one for staff , 2 bathrooms, family room/office, living room, kitchen, dining room, shaded area, indoor and outdoor activity area, laundry room and attached garage.LPA and Administrator toured the entire facility inside and out. Documents are posted as mandated by the DPH and CCLD. Bedrooms 1,3-5 are occupied by clients and contain the mandated furniture. Bedroom 2 is a staff bedroom. The (2) bathrooms are clean and operational. Smoke detectors and carbon monoxide detector are in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients. 1 staff file is current, 1 resident file is current along with medications. The water temperature is at 116.9 degrees. A comfortable temperature is maintained in the facility. Ample supply of perishable and nonperishable food, linens and personal hygiene supplies are adequate, hazardous toxins and/or items are inaccessible to clients, 1 fire extinguishers are fully charged. First Aid kit complete and with manual. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, sanitizer/soap in the staff bathroom and additional sanitation supplies in a locked cabinet located in the office. LPA observed staff and clients wearing masks, an isolation room(clients can isolate in own room if nessary) and required postings throughout the facility. The administrator advised LPA that sanitizer is administered by each client with supervision, sanitizers are kept in their rooms and all clients know how to safely . The facility has an approved Mitigation plan. Visitors are logged and checked. The client’s temperatures are checked and logged 2x a day.According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.An exit interview conducted with Debra Estrada, Administrator and copy of report provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jeremiah Randle
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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