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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602990
Report Date: 03/13/2025
Date Signed: 03/13/2025 03:01:59 PM

Document Has Been Signed on 03/13/2025 03:01 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 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:
03/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:44 PM
MET WITH:Debra EstradaTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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On March 13, 2025, Licensing Program Analyst (LPA) Deborah Lee arrived at facility to conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator

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. LPA discussed facility annual fee status with Administrator.

Structure:

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, dining room/office area, living room, kitchen, outdoor shaded area, laundry room with (2) washers and (2) dryers.

Physical Plant LPA and Co-Administrator Debra Estrada toured the facility inside and outside. LPA observed there were no bodies of water on the premises.

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2025
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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PARK LANE HOME 1
FACILITY NUMBER: 198602990
VISIT DATE: 03/13/2025
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LPA observed that facility had required postings: Facility license, personal rights, “see something, say something,” facility sketch, exit signs, infectious disease postings, Administrator certificates, an emergency disaster plan.

Bedrooms LPA inspected all (5) bedrooms All bedrooms were observed to have the required furniture including beds, dressers, night stands with lamps, chairs, and ample storage space for personal belongings. All bedrooms were observed to be clean, in good repair, and have ample lighting.

Bathrooms LPA inspected the facility bathrooms. In the resident’s bathroom the toilet, faucets, and shower were fully operational. All safety handrails were securely fastened. LPA observed the showers to be clean and free of mold or mildew. The shower had a nonskid material in bottom and shower chair. The water temperature measured 110.8 degrees Fahrenheit. All bathrooms were observed to be clean, in good repair and within Title 22 regulations.

Linens & Hygiene LPA observed all beds to have the required linens including mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed an ample supply of additional linens, towels, and blankets stored in cabinets in attached garage.

Kitchen LPA inspected the kitchen and observed all appliances to be in good working repair. LPA observed knives and additional sharps to be secured in locked safe in a cabinet and are inaccessible to residents. LPA observed a 2--day supply of perishable foods and a 7-day supply of nonperishable foods.

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC809 (FAS) - (06/04)
Page: 2 of 3
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 1
FACILITY NUMBER: 198602990
VISIT DATE: 03/13/2025
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Safety LPA observed and tested smoke/carbon monoxide combo detectors to be fully operable. LPA observed ( 2) fully charged fire extinguishers that was last serviced on 6/4/24. The last emergency drill was conducted on 2/12/25. LPA inspected the First Aid kit and found it contained an ample supply of required items: Scissors, tweezers, gauze, disinfectant wipes, band aids. LPA observed all exits to be clear and easily accessible. All toxins locked and inaccessible to residents in care.

Medications LPA observed all centrally stored medications in their original packaging and are secured in a locked cabinet that is inaccessible to Residents in care.

Files LPA reviewed ( 4 ) resident files and found that (4) out of (4) contained all the necessary documentation. LPA reviewed (3) staff files and found that (3) out of (3) contained the required documentation, certification, and training. Liability Insurance expires on 11/04/2025

Infection Control During the visit, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance. PPE supplies are readily available to staff.

Outside area: During visit LPA observed the outside grounds (front and back) to be free of clutter, debris, and passage ways were free of obstruction.

There were no deficiencies cited during today’s visit. Exit interview conduct and report provided to Administrator Debra Estrada

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC809 (FAS) - (06/04)
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