275294322-9-10-2024-24-AS-SMOA-D98T25-20240918142011

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 275294322
Report Date: 09/10/2024
Date Signed: 09/10/2024 12:14:43 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
07/18/2024 and conducted by Evaluator Mai Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20240718113028

FACILITY NAME:	PARK LANE, THE		FACILITY NUMBER:	275294322
ADMINISTRATOR:	MONTELLANO, ANTHONY		FACILITY TYPE:	740
ADDRESS:	200 GLENWOOD CIR		TELEPHONE:	(831) 373-0101
CITY:	MONTEREY	STATE: CA	ZIP CODE:	93940
CAPACITY:	160	CENSUS: 92	DATE:	09/10/2024
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Donna Lao, Memory Care Director		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Resident developed multiple pressure injuries while in care
Staff do not ensure the facility is kept free of mal odors
Staff do not ensure dental care needs of resident are being met
Staff do not ensure rooms are kept at comfortable temperatures for residents in care

INVESTIGATION FINDINGS:

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On 09/10/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct subsequent complaint visit and deliver findings for the above complaint allegations. LPA introduced self, stated the purpose of the visit and requested to meet with Administrator. LPA met with Memory Care Director Donna Lao who stated Administrator Eva Reiter is unavailable to attend meeting.

During the course of complaint investigation, the department toured the facility, reviewed records, and conducted interviews. R1 is under the care of Hospice with no notes indicating pressure injuries and wounds. The facility was observed free of odors and comfortable temperature with tower fans observed in the resident's room. Resident’s teeth are being brush daily by staff and the resident have been seen by a dentist. Based on observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegations are found to be UNSUBSTANTIATED. Exit interview was conducted. A copy of this report was provided to Memory Care Director, whose signature confirm receipt of this report.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

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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