275294322-8-29-2022-26-AS-SMOA-CQSVEA-20230411162201

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 275294322
Report Date: 08/29/2022
Date Signed: 08/29/2022 09:46:16 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/20/2020 and conducted by Evaluator Mai Yang

COMPLAINT CONTROL NUMBER: 26-AS-20200420143926

FACILITY NAME:	PARK LANE, THE		FACILITY NUMBER:	275294322
ADMINISTRATOR:	SANJAY KABADI		FACILITY TYPE:	740
ADDRESS:	200 GLENWOOD CIR		TELEPHONE:	(831) 373-0101
CITY:	MONTEREY	STATE: CA	ZIP CODE:	93940
CAPACITY:	160	CENSUS: 85	DATE:	08/29/2022
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Administrator Tony Montellano		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Staff handles resident in a rough manner resulting in bruising
Resident sustained skin tears while in care
Staff forces resident to take medication
Staff not responding to resident's complaint of pain
Resident call pendent not working
Staff did not allow resident to make telephone call
Staff did not administer resident oxygen properly

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) M. Yang arrived unannounced on 08/29/22 at 09:45 AM to conclude the complaint investigation. Upon arrival LPA met with Administrator Tony Montellano and stated the purpose of the visit.

A complaint was received on April 20,2020, alleging the following; Staff handles resident in a rough manner resulting in bruising; Resident sustained skin tears while in care ; Staff forces resident to take medication ; Staff not responding to resident's complaint of pain ; Resident call pendent not working ; Staff did not allow resident to make telephone call ; Staff did not administer resident oxygen properly. During the course of the investigation the department conducted interviews and reviewed relevant documents, medical records, residents’ files, medication records, call logs. Based in the information obtained during this time period, the allegations could not be confirmed or corroborated.

The Department has investigated the above mentioned allegations and has determined that the complaint is UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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