275294322-11-14-2024-24-AS-BCHN-DBD2XF-20241125164704

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 275294322
Report Date: 11/14/2024
Date Signed: 11/14/2024 09:11:11 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
08/12/2024 and conducted by Evaluator Vadim Gorban

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20240812163914

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: 153	DATE:	11/14/2024
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Resident Services Director Eva Reiter		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff left resident in soiled diapers resulting in a rash.
Resident sustained pressure sore while in care.

INVESTIGATION FINDINGS:

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On 11/14/2024 Licensing Program Analyst (LPA) V Gorban arrived to complete an unannounced complaint visit to deliver findings. LPA met with RSD Eva Reiter. Administrator was contacted and notified. LPA discussed reason for visit and was permitted entry into facility. LPA completed a health and safety check on residents in care. Residents observed in common areas and in rooms.

Allegation: Staff left resident in soiled diapers resulting in a rash.
During this investigation department requested and reviewed records. During staff interview no statements or records of residents left in soiled diapers available and /or provided by facility. During resident interview no dates when resident being left in wet diaper provided. The records provided stated residents was attended every couple hours throughout the day. Records review revealed the door note not to bother during night time. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Report continues on attached LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim Gorban	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

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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Control Number 24-AS-20240812163914

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 11/14/2024

NARRATIVE

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Allegation: Resident sustained pressure sore while in care.

During complaint investigation department completed interviews with staff, resident, family member, and reviewed facility records. R1 was observed to be on hospice. Hospice records indicated that R1 had a redness at time of admittance to Hospice. However, the redness was not noted whether it had grown in size. The facility records indicated resident was checked was check every couple hours by facility staff. The records provided stated residents was attended every couple hours throughout the day. Records review revealed the door note not to bother during night time. 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.

No deficiency were observed during this visit.
Exit interview conducted, report signed and copy of this report provided for facility records.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim Gorban	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

LIC9099 (FAS) - (06/04)

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