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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 275294322
Report Date: 03/29/2024
Date Signed: 07/30/2024 09:23:56 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 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
02/12/2024 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 24-AS-20240212083924
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:
03/29/2024
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator, Billy MitchellTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff did not ensure that facility has adequate food for the residents.
Staff did not ensure that facility has hot water for the residents.
Staff did not respond to the residents' pendants when asking for help.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt arrived unannounced to deliver findings on the allegations listed above. LPA met with Administrator, Billy Mitchell, and explained the purpose of today's visit.


Regarding the allegation Staff did not ensure that facility has adequate food for the residents. LPA interviewed five facility residents who stated the facility does provide three meals day, and there has never been a day where the facility has not supplied food. Resident 1 stated there was a few weeks recently when the kitchen would run out of items but it was usually small side items, and full meals were always provided. Based on interviews conducted, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 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
02/12/2024 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 24-AS-20240212083924

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:
03/29/2024
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator, Billy MitchellTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff mismanaged the residents' medications.
Staff mismanaged the residents' records.
INVESTIGATION FINDINGS:
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2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Sarah Hurt arrived unannounced to deliver findings on the allegations listed above. LPA met with Administrator, Billy Mitchell, and explained the purpose of today's visit.

Regarding the allegation Staff mismanaged the residents' medications. Resident 4's medication was delivered to the facility and placed in a refrigerator in the facility medication room. Resident 4's medication was not provided to them as it was not given to persons responsbile for administering the medication. Resident 5 is to take a speciifc medication, 1 tablet by mouth every 7 days 30 minutes prior to meal with a glass of water. Resident 5 has not been given the medication for more than 21 days as noted on Medication Administration Record. Based on LPA's interview conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Continued..
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 24-AS-20240212083924
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: PARK LANE, THE
FACILITY NUMBER: 275294322
VISIT DATE: 03/29/2024
NARRATIVE
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Continued..

Regarding the allegation Staff mismanaged the residents' records. Facility staff did not have required Centrally Stored Medication Log for Resident 4's medication being stored by the facility. Resident 6's medication being stored by the facility is not logged on the facilities Centrally Stored Medication Record. Based on LPA interviews conducted, and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.


Exit interview conducted with Administrator, Billy Mitchell, and a copy of this report, along with appeals rights provided.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 24-AS-20240212083924
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PARK LANE, THE
FACILITY NUMBER: 275294322
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/30/2024
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
.(4) The licensee shall assist residents with self-administered medications as needed. The following requirement has not been met as evidenced by:
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Administrator agrees to conduct in service training on communication between medication technicians, the pharmacy, and the delivery of the medication and submit proof to LPA by PO date of 03/30/2024.
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Resident 4 was not provided prescribed medication as facility did not provide the medication to person responsible for administering, Resident 5 has not been given prescribed weekly medication for more than 2 weeks, which poses an immediate, health, safety or personal rights risk to resident in care.
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Type B
04/12/2024
Section Cited
CCR
87465(6)
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87465 Incidental Medical and Dental Care (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:
(A) The name of the resident for whom prescribed.(B)The name of the prescribing physician.(C) The drug name, strength and quantity.(D) The date filled.
(E) The prescription number and the name of the issuing pharmacy.(F) Instructions, if any, regarding control and custody of the medication. The following requirement has not been met as evidenced by:
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Administrator agrees to provide in service training with medication technicians on medication documentation 04/12/2024.
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Resident 4's medication was being stored by the facility with no Centrally Stored Medication Record, Resident 6's medication stored by the facility is not logged on the Centrally Stored Medication log, which poses a potential, health, safety or personal rights violation to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 24-AS-20240212083924
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: PARK LANE, THE
FACILITY NUMBER: 275294322
VISIT DATE: 03/29/2024
NARRATIVE
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Continued..


Regarding the allegation Staff did not ensure that facility has hot water for the residents. LPA's interviewed five facility residents who all stated the facility has hot water. Resident 2 stated there was an incident during a weather related power outage where they did not have hot water for a few hours, but it was fixed before the day was over. Administrator stated recently during a weather related power outage there was a maintenance issue when the power was restored effecting the facility hot water. Administrator stated maintenance was notified, and the hot water was restored within the same day. LPA Hurt measured several facility resident room water temperatures to be within required 105 and 120 degrees. Based on interviews conducted, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.


Regarding the allegation Staff did not respond to the residents' pendants when asking for help.
LPA's interviewed 5 facility residents who all stated despite having to wait longer at times on the weekends they are assisted timely when they push their pendant. Resident 3 stated when she pushes her pendant facility staff come fast to check to see if assistance is needed. LPA Hurt facility records titled "Device Activity Report" which documented wait times for assistance to be on average under 15 minutes. Based on interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.


Exit interview conducted with Administrator, Billy Mitchell, and a copy of this report, along with appeals rights provided.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5