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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 275294322
Report Date: 12/02/2022
Date Signed: 12/02/2022 01:33:58 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/28/2022 and conducted by Evaluator Mai Yang
COMPLAINT CONTROL NUMBER: 24-AS-20221128135330
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: 83DATE:
12/02/2022
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Candice Moses, Interim Executive DirectorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not administer a resident's medications as required
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/2/22, Licensing Program Analyst (LPA) M. Yang conducted an unannounced initial 10-day complaint visit. LPA introduced self and requested to meet with the Administrator. LPA met with Candice Moses, Interim Executive Director and explained the purpose of visit.

During the course of the investigation, the department reviewed records and conducted interviews. Based on interviews conducted, R1 self-managed R1’s own medication until a new physician’s order and medication was received at the facility. After which, staff began administering resident’s medications as order.

Based on interviews conducted, the preponderance of evidence standard has not been met, therefore the above allegation is found to be UNSUBSTANTIATED. An exit interview was conducted. A copy of this report was provided to the Interim Executive Director.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/28/2022 and conducted by Evaluator Mai Yang
COMPLAINT CONTROL NUMBER: 24-AS-20221128135330

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: 83DATE:
12/02/2022
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Candice Moses, Interim Executive DirectorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not provide adequate supervision to a resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/2/22, Licensing Program Analyst (LPA) M. Yang conducted an unannounced initial 10-day complaint visit. LPA introduced self and requested to meet with the Administrator. LPA met with Candice Moses, Interim Executive Director and explained the purpose of visit.

During the course of the investigation, the Department toured the facility and conducted interviews. Resident’s safety checks are conducted by staff each shift. R1 confirmed staff checks in on resident daily.

Based on interviews conducted, the allegation above is UNFOUNDED, meaning they were false, could not have happened, and/or are without reasonable basis. We have therefore dismissed the complaint. An exit interview conducted. A copy of this report was provided to the Interim Executive Director.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2