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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 310311880
Report Date: 02/17/2022
Date Signed: 02/18/2022 10:51:41 AM


Document Has Been Signed on 02/18/2022 10:51 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
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:
02/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Tito Andrada and Tito Andrada, Jr.TIME COMPLETED:
04:30 PM
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On 2/17/2022 LPA Tryon arrived at the facility to do an annual visit, using the Infection Control Domain of the CARES Tool. LPA met with staff Tito Andrada and Tito Andrada, Jr.
LPA did a tour of the facility including common areas, kitchen, bedrooms, bathrooms, storage, yard. The facility appears to be in substantial compliance at this time. The home has adequate supplies of food, 2 days perishable and 7 days non-perishable. The facility appears to be clean and adequately furnished.

LPA reviewed the Infection Control Domain with staff. The facility continues to follow COVID protocols. To date there have been no positive COVID cases.

At this time, the facility appears to be in substantial compliance.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 208-7709
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022
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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