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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275294322
Report Date: 02/22/2024
Date Signed: 02/23/2024 08:15:28 AM


Document Has Been Signed on 02/23/2024 08:15 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
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: 217DATE:
02/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Billy Mitchell - Executive DirectorTIME COMPLETED:
05:00 PM
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On 2/22/2024, Licensing Program Analyst(LPA) D. Ayers arrived unannounced to conduct a Required Annual Inspection. LPA met with Executive Director Billy Mitchell and announced the purpose of the visit.

LPA toured the facility inside and outside. All passageways and exits were clear and free from obstruction. Fire extinguishers were recently serviced and facility had a sprinkler system. The facility kitchen was clean and had an adequate supply of perishable and non-perishable foodstuffs. Food was stored properly. LPA observed emergency food supply and personal protective equipment. Facility had adequate supply of emergency food and first aid supplies. LPA reviewed emergency-disaster plan, including evacuation plan and emergency drills. Plan of operations included requirements for dementia care.

Common areas were clean, well-lit, and odor-free. LPA toured a sample of resident bedrooms and bathrooms, which were observed to be clean, with all fixtures and appliances functioning properly. Bathrooms were clean and were equipped with required grab-bars and non-skid mats. LPA toured facility memory care unit. LPA observed centrally stored medications in assisted living and memory care to be properly stored and secured, and medications appeared to be administered properly. Facility had an activities coordinator and assistants, and LPA reviewed planned activities. LPA reviewed a sample of resident and staff files. Files contained required documentation and records. LPA requested the following files to be provided by 2/29/2024: LIC 500, LIC 308, LIC 9020a, LIC 610E.

No deficiencies were cited during the inspection. A copy of the report was provided and exit interview conducted with Executive Director.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David AyersTELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024
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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