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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275294322
Report Date: 09/06/2024
Date Signed: 09/07/2024 03:54:32 PM


Document Has Been Signed on 09/07/2024 03:54 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: 82DATE:
09/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Resident Services Director Eva ReiterTIME COMPLETED:
02:00 PM
NARRATIVE
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On 09/06/2024, Licensing Program Analyst (LPA) V Gorban arrived at the facility unannounced to conduct a case management inspection. LPA met with Resident Services Director Eva Reiter and announced the purpose of the inspection. Executive Director Billy Mitchell was no longer with the company and was not available to assist with the visit.

The purpose of the inspection was to follow-up on an incident which occurred on 08/12/2024. On 8/12/2024, care provider (CP1) was sharing with resident (R1) inappropriate videos of himself engaging with intimate contact with an unknown female. CP1 was suspended on 08/12/2024 pending investigations. Responsible party of R1 was not notified of the incident due to resident request. Staff was terminated on 08/30/2024.

Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiency was observed and cited on the attached LIC 809-D. Failure to correct the deficiency may result in civil penalties.
An exit interview was conducted, and a copy of this report provided to the licensee via email. Appeal Rights (LIC 9058) were provided to the licensee.

Exit interview conducted, report signed and copy of this report provided for facility records.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024
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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Document Has Been Signed on 09/07/2024 03:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: PARK LANE, THE
FACILITY NUMBER: 275294322

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/09/2024
Section Cited
CCR
87468.1(a)(2)

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87468.1 Personal rights. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations. This requirement was not met as evidenced by:
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The facility staff provided internal investigation and terminated S1. RSD also will provide in-service training to all staff on residents privacy and dignity and will provided a report to LPA by email by POC due date.
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Based on records review the facility staff (S1) shared personal inappropriate video content of him with another individual with residents (R1 and R2) in care. This poses potential health and safety risk to persons 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) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024
LIC809 (FAS) - (06/04)
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