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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602990
Report Date: 03/10/2023
Date Signed: 03/10/2023 03:55:40 PM

Document Has Been Signed on 03/10/2023 03:55 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, 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:
5624269616
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY: 4CENSUS: 4DATE:
03/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:33 AM
MET WITH:Debra J. Estrada - Co-AdministratorTIME COMPLETED:
04:19 PM
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Licensing Program Analyst (LPA) Mario Leon made an unannounced Required - 1 Year inspection to the above Adult Residential Facility (ARF). LPA Leon met with Diana Serpas, DSP (D1) and Lucresia Teodoro, DSP, and later by Debra J. Estrada, Co-Administrator. LPA Leon informed staff that the purpose of today's visit was to inspect the adult residential facilities' physical plant, review staff and client’s records.
The facility is licensed to serve four (4) developmentally disabled clients, of which two (2) may be non-ambulatory, aged 18-59 years. Two (2) of their clients are above the age of 59, with a hospice waiver for two (2).

LPA Leon verified current staff fingerprints that are cleared and associated to the facility. The ARF annual fees are current. The ARF is vendored by Harbor Regional Center (HRC).

LPA Leon and D1 toured the entire facility, inside and out. The Adult Residential Facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) bedrooms one (1) for staff , Two (2) bathrooms, family room/office/physical activity room, living room, kitchen, dining room, shaded area, indoor and outdoor activity area, laundry room and attached garage. Documents are posted as mandated by the DPH and CCLD. Bedrooms one and three through five (1,3-5) are occupied by clients and contain the mandated furniture. Bedroom two (2) is a staff bedroom. The two (2) bathrooms are clean and operational. Smoke detectors and carbon monoxide detector are in compliance and operational. No firearms are stored at the facility and no bodies of water are present. Medications are centrally stored, locked and inaccessible to clients. Staff files are current, resident files are also current along with medications admissions record (MARs). The water temperature was measured at 117.6 F. A comfortable temperature is maintained in the facility, at 68.7 F. Ample supply of perishable and nonperishable food, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to clients, 1 fire extinguisher located at the corner between the kitchen and living room is fully charged and the last fire drill was conducted on 2/17/2023. First Aid kits and supplies are complete and with manual. See LIC809-C
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PARK LANE HOME 1
FACILITY NUMBER: 198602990
VISIT DATE: 03/10/2023
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Exits, walkways and/or passageways, front and back yards 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 necessary) and required postings were posted 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 use safely. The facility has an approved Mitigation plan. Visitors are screened and logged, checked with questionnaire at the front door which is automatically sent to the ARF email.

There were no deficiencies cited today.

An exit interview was held and this report was provided to Co-administrator Debra J. Estrada
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC809 (FAS) - (06/04)
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