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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 275294322
Report Date: 11/20/2024
Date Signed: 11/24/2024 01:01:18 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 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
06/26/2024 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 24-AS-20240626094201
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: 185DATE:
11/20/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Regional Director of Operations, Aaron WindbiglerTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Facility staff did not seek timely medical attention for resident
Facility staff did not provide refund to resident's responsible person
Facility staff did not follow admissions agreement
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt arrived unannounced to deliver findings on the allegations listed above. LPA met with Aaron Windbigler, and explained the purpose of todays visit.

Regarding the allegation Facility staff did not seek timely medical attention for resident. Resident fell on 01/14/2024 early morning between 5 a.m., and 6:45 a.m. did not complain of pain. Resident 1's Responsible Party was contacted but was not available. Resident 1 was showing signs of pain in right foot and knee around 10:27 a.m. on 01/14/24 and was “unable to stand and bear weight on leg/foot.” Resident 1 was taken to the hospital by Responsible Party at 8 p.m. on 01/14/2024. Responsible Party stated Resident 1 was in a wheelchair upon arrival and in visible pain. Based on LPA's interviews conducted, and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
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 4
Control Number 24-AS-20240626094201
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: PARK LANE, THE
FACILITY NUMBER: 275294322
VISIT DATE: 11/20/2024
NARRATIVE
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Regarding the allegation Facility staff did not provide refund to resident's responsible person. The facility acknowledges Resident 1's Responsible Party is owed refund of 40% of the 6,000 dollar "Community Fee." Resident 1's Responsible Party has not been refunded this portion of the "Community Fee" Based on LPA interviews conducted and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.


Regarding the allegation Facility staff did not follow admissions agreement. The facilities Admission Agreement documents "D. Community Fee (v) If this agreement terminates and you leave the community, for any reason, during the third month of residency, you will be entitled to a refund of forty percent (40%) of the balance after a $500 fee is deducted. The facility has not refunded Resident 1's Responsible party for entitled portion of fee, therefore is not following Admissions Agreement. Based on LPA interviews conducted, and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.


The following deficiencies are being cited Per Title Regulations, Exit interview conducted with Aaron Windbigler, and a copy of this report along with appeals rights provided.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 24-AS-20240626094201
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: PARK LANE, THE
FACILITY NUMBER: 275294322
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/21/2024
Section Cited
CCR
87465(a)
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87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The following requirement has not been met as evidenced by:
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Regional Director of Operations agrees to provide facility staff training on the subject of timely medical care, and submit proof to LPA by POC date of 11/21/2024.
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Resident 1 fell on 01/14/2024 around 05:00 a.m., despite being in visible pain was not provided medical care until 8 p.m., which poses an immediate, health, safety or personal rights risk to resident in care.
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Type B
12/04/2024
Section Cited
HSC
1669.652
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§1569.652 Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed. The following requirement has not been met as eveidenced by:
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The facility will refund 40 percent of 6,000 admission fee to Resident 1's Responsible Party and submit to LPA by POC date of 12/04/2024.
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The facility has not refunded portion of "Community fee" to Resident 1's Responsible Party more than 15 days after the passing of Resident 1, which poses a potential, health, safety, or personal rights risk to residents 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.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 24-AS-20240626094201
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: PARK LANE, THE
FACILITY NUMBER: 275294322
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/04/2024
Section Cited
CCR
875057(a)(f)
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87507 Admission Agreements (a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any.(f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. The following requirement has not been met as evidenced by:

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Regional Director of Operations agrees to Sales Marketing staff, and also Business Office on reviewing agreements and refund process, and submit to LPA Hurt by 12/04/2024.
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Resident 1's Admission Agreement reads 40 percent of "Community Fee" should be refunded. Resident 1's Responsible Party has not received refund, which poses a potential, health, safety, or personal rights risk to residents 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.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4