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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275294322
Report Date: 01/08/2025
Date Signed: 01/10/2025 08:27:17 AM

Document Has Been Signed on 01/10/2025 08:27 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:PARK LANE, THEFACILITY NUMBER:
275294322
ADMINISTRATOR/
DIRECTOR:		MONTELLANO, ANTHONYFACILITY TYPE:
740
ADDRESS:200 GLENWOOD CIRTELEPHONE:
(831) 373-0101
CITY:MONTEREYSTATE: CAZIP CODE:
93940
CAPACITY: 160CENSUS: 81DATE:
01/08/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:42 AM
MET WITH:Resident Services Director Eva ReiterTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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On 01/08/2025 LPA Gorban visited the facility to conduct health and safety checks of clients in care. LPA introduced self, stated the purpose of the visit and was allowed entry. Administrator was notified of Licensing visit and was able to attend it.
During this visit LPA toured inside and outside of the facility, interviewed facility staff and administrator.

This visit was conducted in regard to incident report provided to Licensing office that occurred on 12/28/2024 were medication error occurred. During this event resident (R1) was provided and taken wrong medications. Based on file review and interview of facility staff, responsible party was notified and resident was monitored. No adverse side effects observed during monitor period.

Based on interviews and records reviews the deficiency cited on attached LIC809-D in accordance with the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8. Failure to correct the deficiency, or repeat violations, may result in civil penalties.

Exit interview with Appeal Rights (LIC 9058) and a copy of this report was provided for facility records.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025
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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Document Has Been Signed on 01/10/2025 08:27 AM - It Cannot Be Edited


Created By: Vadim Gorban On 01/08/2025 at 09:43 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: PARK LANE, THE
FACILITY NUMBER: 275294322

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/10/2025
Section Cited
CCR
87465(c)(2)

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87465 Incidental Medical and Dental Care. (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not observed as evidenced by:
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Facility plan is to provide additional staff training and close monitoring of medication dispensing especial for on boarded staff members. Proof of training will be provided to Licensing office /LPA by email by POC due date 01/10/25
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Based on interview and records review the facility failed to ensure R1 medication as prescribed. R1 took wrong medications ( dose of Mitrazapine and Risperidone instead of prescribed Ramipril) which poses potential health and safety risk to persons 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.
SUPERVISOR'S NAME:Brenda Chan
LICENSING EVALUATOR NAME:Vadim Gorban
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2025


LIC809 (FAS) - (06/04)
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