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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275294322
Report Date: 12/16/2020
Date Signed: 12/22/2020 09:43:29 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:PARK LANE, THEFACILITY NUMBER:
275294322
ADMINISTRATOR:BEAU A. AYERSFACILITY TYPE:
740
ADDRESS:200 GLENWOOD CIRTELEPHONE:
(831) 373-0101
CITY:MONTEREYSTATE: CAZIP CODE:
93940
CAPACITY:125CENSUS: 77DATE:
12/16/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Beau AyersTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted a Technical Assist (TA) Visit via Zoom platform with Beau Ayers Executive Director/ Administrator, Barbara Elenteny Program Clinical Consultant (PCC) Nurse, California Department of Social Services and Sarah Yip Licensing Program Manager. The purpose of the visit was to provide technical assistance for Infection Prevention and Control guidelines for Adult and Senior Care facilities. LPA conducted a virtual tour of the facility. LPA and PCC reviewed the facility policies and procedures to include screening, disinfecting, staffing, training, PPE usage, Doffing and Donning of PPE, supplies and resident activities.

The following recommendations were discussed:

1. Post Donning and Doffing signage outside and inside of Isolation room(s).
2. Maintain covered trash can inside Isolation room for proper disposal of contaminated PPE.
3. Maintain social distancing by placement of chairs in the dining and living room areas of Memory Care.

LPA forwarded PPE informational Links for review.

Report reviewed with Beau Ayers and copy emailed for signature purposes.
SUPERVISOR'S NAME: George NwaforTELEPHONE: (650) 269-7419
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE:
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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