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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275294322
Report Date: 02/22/2023
Date Signed: 02/22/2023 12:19:15 PM


Document Has Been Signed on 02/22/2023 12:19 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: 72DATE:
02/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH:Billy Mitchell, Executive Director
Alex Hernandez, Maintenance Director		TIME COMPLETED:
12:20 PM
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On 2/22/2023, Licensing Program Analysts (LPAs) M. Medina and D. Ayers arrived at the facility unannounced to conduct an Annual Required Inspection. LPA's introduced self and stated purpose of visit. LPA's met with Executive Director. LPA's was greeted by screener, COVID screening was completed prior to LPA's entry. LPA's 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.

LPAs toured the facility inside and out with Alex Hernandez, Maintenance Director. Required postings observed throughout the facility. Staff were all observed wearing face coverings. Facility has a minimum of 30 day supply of PPE and resident medications.

LPA received copies of current resident roster during inspection visit. Executive Director to submit updated LIC 500, LIC 610 and copy of Administrator qualifications to Fresno Regional Office no later than 3/08/2023.

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, report signed and 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: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023
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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