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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602990
Report Date: 04/26/2024
Date Signed: 04/26/2024 10:47:29 AM

Document Has Been Signed on 04/26/2024 10:47 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:PARK LANE HOME 1FACILITY NUMBER:
198602990
ADMINISTRATOR/
DIRECTOR:
SHELLA MANALANGFACILITY TYPE:
735
ADDRESS:3145 PARK LANETELEPHONE:
(562) 426-9616
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY: 4CENSUS: 4DATE:
04/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:24 AM
MET WITH:Administrator Debra EstradaTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On 04/26/24, Licensing Program Analyst (LPA) Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator Debra Estrada, as the purpose of the visit was explained. The facility is licensed to serve (4) ambulatory adults ages 18-59 that are developmentally disabled, of which (2) may be non-ambulatory. Current census is (4), clients are linked to the harbor regional center. Facility fees are current.

The facility is a single-story structure located in a residential neighborhood and consists of the following: (5) bedrooms of which (1) bedroom is for staff, (2) bathrooms, dinning room/office area, living room, kitchen, outdoor shaded area, laundry room with (2) washers and (2) dryers, and attached garage that has workout equipment. Client bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to clients. The water temperature properly measured between 105-120 F.. A supply of perishable and non-perishable food was observed, toxins and knifes were stored and inaccessible to clients, no weapons nor bodies of water on the premises, exits and walkways are free of debris/hazards.

LPA conducted a records review of 2 staff records, 4 client records, (3) P&I records, and 2 medication administration records, no discrepancies observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire was conducted on 04/18/24, fire extinguisher fully charged, carbon monoxide and smoke detectors are interconnected and operational.

Exit interview conducted with Administrator Debra Estrada, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2024
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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