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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275294322
Report Date: 07/28/2022
Date Signed: 07/28/2022 01:13:26 PM


Document Has Been Signed on 07/28/2022 01:13 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
CCLD Regional Office, 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: 85DATE:
07/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Anthony Montellano and Beau AyersTIME COMPLETED:
01:35 PM
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On 7/28/22, Licensing Program Analyst (LPAs), M. Medina and V. Gorban conducted an unannounced Annual Required Infection Control Inspection. LPA was greeted by screener, COVID screening was completed prior to LPA's entry. LPA observed a central entry point with a supply of hand sanitizer located upon entry. A sign in policy that includes documented routine symptom screening for visitors is currently being implemented to follow current visitation guidelines. All staff utilize main entrance with COVID infection protocols prior to starting shift. Mitigation plan was received and approved by Department.

LPAs toured the facility with Anthony Montellano, Executive Director and Beau Ayers, Regional Vice President of Operations. Required postings of signs to include hand washing, coughing etiquette and physical distancing were observed throughout the facility. Staff were all observed wearing face coverings. Facility has designated visitation areas. LPAs observed a 30 day supply of PPE and resident medications. Several residents rooms in Assisted Living, and Memory Care toured and observed to have adequate soap and paper products available.

Through LPA's observation of documentation and interview with Administrator, the required infection control practices are found to be in compliance. No deficiencies were observed.

Exit interview was conducted and report signed. A copy of this report provided for facility records.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022
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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