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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 310311880
Report Date: 02/23/2023
Date Signed: 02/24/2023 08:37:40 AM


Document Has Been Signed on 02/24/2023 08:37 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
CHICO - RESIDENTIAL, 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:
02/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Tito Andrada and Tito Andrada Jr. TIME COMPLETED:
03:00 PM
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.On 2/23/23 LPA Tryon visited the facility to do an annual visit using the Infection Control Domain of the Care Tool.

LPA reviewed the Infection Control section with the licensee and Administrator.

LPA toured the facility including common areas, kitchen, diningroom, bedrooms, hallways, bathrooms, storage. The home is clean and in good repair. Smoke detectors installed, fire extinguishers present and charged. There are adequate food supplies, PPE, cleaners, and other supplies. Medications centrally stored and locked.

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

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2023
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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