275294322-1-10-2025-24-AS-VGON-DCSMAE-20250110082611

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 275294322
Report Date: 01/08/2025
Date Signed: 01/10/2025 08:26:28 AM

Document Has Been Signed on 01/10/2025 08:26 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, THE		FACILITY NUMBER:	275294322
ADMINISTRATOR/ DIRECTOR:	MONTELLANO, ANTHONY		FACILITY TYPE:	740
ADDRESS:	200 GLENWOOD CIR		TELEPHONE:	(831) 373-0101
CITY:	MONTEREY	STATE: CA	ZIP CODE:	93940
CAPACITY: 160	TOTAL ENROLLED CHILDREN: 0	CENSUS: 81	DATE:	01/08/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:30 AM
MET WITH:	Administrator Natasha Prunty		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 01/08/2025, Licensing Program Analyst (LPA) V Gorban arrived at the facility unannounced to conduct Required Annual Inspection. LPA met with Administrator (AD) Natasha Prunty. LPA conducted tour inside and out of facility with AD. Residents observed at the facility during lunch time. The facility was observed to be at a comfortable temperature of 76 degrees, clean, in good repair, and no passageway obstructions or fire hazards observed. Fire extinguisher was observed with a service date of 10/04/2024 Dining area and Kitchen were toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in freezer, refrigerator, and pantry. Food is delivered by US Foods twice a week on Tuesdays and Fridays. Refrigerator temperature was maintained at 39.0-degree F. and freezer was maintained at -2-degree F. Residents' rooms were toured and observed with adequately furnished with bed, dresser, and adequate lighting. Hot water temperature tested and within regulation requirements. LPA observed securely fastened grab bar and non-skid mat in shower area. Medications were stored in a locked medication room in a medication cart. Medications records were reviewed. First Aid Kit was stored in medication room and observed with all required items. Adequate PPE supplies was observed. LPA toured laundry room and observed chemicals were stored and locked for staff use only. Facility courtyard was toured and observed to be free from debris. There was outdoor seating available for the residents. Report continues on attached LIC809-C

Brenda Chan	TELEPHONE: (650) 266-8889
Vadim Gorban	TELEPHONE: (559) 243-8080
	DATE: 01/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025

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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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
	VISIT DATE: 01/08/2025

NARRATIVE

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Residents’ files were reviewed to have updated emergency contact, Admission agreement, Needs and Services Plan and Pre-Appraisal Plan. A sample of staff files were reviewed. Staff files were observed to have current First Aid/CPR, Health screening, and Personnel record. Staff are fingerprinted clear and associated to the facility.
Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below:

Residential Care Facility for the Elderly (RCFE):

· LIC 308 Designation of Facility Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly
· LIC 9020 Register of Facility Clients/Residents

Please submit the above forms/information to Fresno CCL by: 01/12/2025

As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed.

No deficiencies issued during this inspection. An exit interview was conducted with the AD.

A copy of this report was given to the AD, whose signature on this form confirm receipt of these reports.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim Gorban	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025

LIC809 (FAS) - (06/04)

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