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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 310311880
Report Date: 09/27/2021
Date Signed: 09/28/2021 09:21:39 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:VILLAGE LANE RESIDENCEFACILITY NUMBER:
310311880
ADMINISTRATOR:ANDRADA, TITOFACILITY TYPE:
740
ADDRESS:155 VILLAGE LANETELEPHONE:
(530) 823-6335
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:6CENSUS: 6DATE:
09/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Tito Andrada and Tito Andrada Jr.TIME COMPLETED:
01:00 PM
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LPA Tryon arrived at the facility on 9/27/21 to perform an annual visit using the Infection Control Domain. Prior to the visit, LPA had checked with the facility to ensure they do not have any COVID Positive Residents or staff. LPA did a self-screening by taking temperature and reviewing possible symptoms. LPA wore a surgical mask and used hand sanitizer. LPA met with Tito Andrada and Tito Andrada Jr.

LPA toured the facility including common areas, kitchen, bedrooms, bathrooms, hallways, patio, yard.

LPA reviewed the infection control domain with the Administrator. LPA requested a copy of most recent Administrator Certificate, copy of liability insurance, and current staff schedule.

A Technical Advisory was issued regarding N-95 Fit Testing. The facility is in the process of finding a resource.

The facility appears to be in substantial compliance at this time.

Exit interview conducted
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 208-7709
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021
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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