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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275294322
Report Date: 07/21/2026
Date Signed: 08/20/2026 12:03:23 PM

Document Has Been Signed on 08/20/2026 12:03 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:PARK LANE, THEFACILITY NUMBER:
275294322
ADMINISTRATOR/
DIRECTOR:		RYAN GOLZEFACILITY TYPE:
740
ADDRESS:200 GLENWOOD CIRTELEPHONE:
(831) 373-0101
CITY:MONTEREYSTATE: CAZIP CODE:
93940
CAPACITY: 160CENSUS: 121DATE:
07/21/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:58 AM
MET WITH:Regional Director Terry RoseTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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On 07/21/2026, Licensing Program Analyst (LPA) V Gorban arrived unannounced to conduct a Case Management visit. LPA met with facility Regional Director of Operations (RD) Terry Rose and stated the purpose of the visit.

During visit was discovered that facility recent incident while painting third floor lobby by elevator triggered fire alarm and respond of local fire department.

Based on interviews, incident occurred late evening on July 2nd, 2026. Facility have not provided incident report to Licensing office regarding the fire alarm or Fire Department visits. Deficiency regarding reporting requirements cited on attached LIC809-D form.

In addition, the facility currently missing active administrator for over 30 days. Deficiency regarding administrators qualifications and duties cited on attached LIC809-D

Exit interview conducted, report signed and copy of this report with appeal rights provided to RD for facility records.

Shawna Doucette
Vadim Gorban
DATE: 07/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 08/20/2026 12:03 PM - It Cannot Be Edited


Created By: Vadim Gorban On 07/21/2026 at 12:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: PARK LANE, THE
FACILITY NUMBER: 275294322

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/27/2026
Section Cited
CCR
87211(a)

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Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: This requirement was not observed as evidenced by:
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Licensee will review reporting requirements with leadership team and staff. Following POC due date, will provide correction to LPA by email.
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The License failed to report to the following incidents to the department:
1. fire alarm activation due to late evening painting over smoke detectors.
2. remodel of the main dining room, which poses potential health and safety risk to persons in care.
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Type B
07/27/2026
Section Cited
CCR87405(a)

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Administrator - Qualifications and Duties.(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement was not observed as evidenced by:
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Licensee actively recruiting new executive director, also using outside recruiting agency and will provide updates to LPA by email by POC due date.
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The Licensee failed to ensure the facility has a current and qualified administrator, which 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.
Shawna Doucette
NAME OF LICENSING PROGRAM MANAGER:
Vadim Gorban
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2026


LIC809 (FAS) - (06/04)
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