<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275294322
Report Date: 02/22/2023
Date Signed: 02/22/2023 12:45:33 PM


Document Has Been Signed on 02/22/2023 12:45 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:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Lillian Bennett-Russell, Memory Care DirectorTIME COMPLETED:
12:50 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 2/22/2023, Licensing Program Analysts (LPAs) M. Medina and D. Ayers conducted an unannounced Case Management visit to follow up on an incident received in Fresno Regional Office on 2/22/2023 via fax involving R1.

LPAs met with and toured Memory Care Unit with Lillian Bennett- Russell during Case Management visit.

Incident occurred on 2/19/23 at approximately 9:00 PM. R1 was transported to hospital via ambulance and admitted for treatment. Facility to provide all discharge paperwork for R1 upon return to facility. At this time, R1 is expected to return to facility on or about 2/25/23.

No deficiencies cited during Case Management visit.

Exit interview conducted. Report signed on site and a copy of report provided to Memory Care Director 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)
Page: 1 of 1