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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275294322
Report Date: 01/18/2024
Date Signed: 01/19/2024 12:46:51 PM


Document Has Been Signed on 01/19/2024 12:46 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:PARK LANE, THEFACILITY NUMBER:
275294322
ADMINISTRATOR:MONTELLANO, ANTHONYFACILITY TYPE:
740
ADDRESS:200 GLENWOOD CIRTELEPHONE:
(831) 373-0101
CITY:MONTEREYSTATE: CAZIP CODE:
93940
CAPACITY:160CENSUS: 215DATE:
01/18/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Executive Director, Billy MitchellTIME COMPLETED:
12:30 PM
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On 01/18/24, Licensing Program Analyst (LPA) V Gorban conducted an unannounced Case Management visit. LPA introduced self and was allowed entrance by staff. LPA met with Billy Mitchell, Executive Director (ED) and stated reason for the visit.

LPA arrived at the facility to conduct case management visit to relay information about Immediate Exclusion order for Staff (S1). ED was advised an exclusion has been ordered and issued by the Department and provided an exclusion order document for the S1.
LPA verified with ED that S1 has not worked in facility. ED responded that S1 has not been with the facility since 3/07/2019 .
ED was advised to disassociate S1 from facility staff roster and guardian.

No deficiencies sited during this Case Management visit.

Exit interview was conducted, report signed on-site, and a copy of this report provided to ED for facility records.

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024
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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