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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 310311880
Report Date: 05/02/2024
Date Signed: 05/03/2024 10:58:41 AM


Document Has Been Signed on 05/03/2024 10:58 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
05/02/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Tito Andrada and Tito Andrada, Jrs.TIME COMPLETED:
02:00 PM
NARRATIVE
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On May 2, 2024 LPA Tryon visited the facility to do a case management visit, to follow up on a recent visit from Alta California Regional Center during which several issues were noted. LPA met with Licensee Tito Andrada and Administrator Tito Andrada, Jr.

During a Title 17 Review visit ACRC staff found that staff S1 was hired at the facility in 2021 and she did not have a TB clearance until March 2024. LPA reviewed documentation and spoke with licensee and Administrator, who confirmed that this is true.

ACRC staff also noted that staff in the home did not have CEU Training during the calendar year 2023. LPA verified that staff did receive multiple hours of training in December 2022 and also in January 2024. However, training was not done in calendar year 2023. So, technically, the home did not meet the requirement of 20 hours ANNUAL training as per Health and Safety Code 1569.625.

ACRC staff noted that a medication for resident R1 had a MAR medication sheet which listed that the resident should take 1 pill per day; but there was no specific dosage listed on the medication bottle.

The following deficiencies were cited as per Title 22 Regulations and the Health and Safety Code. Exit interview conducted, appeal rights provided.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 05/03/2024 10:58 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: VILLAGE LANE RESIDENCE
FACILITY NUMBER: 310311880

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/03/2024
Section Cited
CCR
87411(f)

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All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physical not more than six (6)
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The facility will ensure that in the future all staff have a physical exam and TB test as per regulation timelines.
The facility has already obtained a physician report and TB clearnace for S1 at this time. POC is cleared.
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months prior to or seven (7) days after employment or licensure.
This requirement was not met as evidenced by: through review it was found that staff S1 was hired in 2021 and did not have a TB clearance until March 2024.
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Type B
06/03/2024
Section Cited
HSC1569.625

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The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training...training requirements shall also include an additional 20 hours annually
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The facility will ensure that all staff meet the intial and ongoing training requirements as per regulation.

Administrator will submit a plan of how he will ensure that all facility staff obtain required hours of training each year dating from their
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This regulation is not met as evidenced by: through record review it was found that staff at the facility received training in December 2022 and in January 2024, but technically did not receive any training in calendar year 2023.
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date of employment.
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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 05/03/2024 10:58 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: VILLAGE LANE RESIDENCE
FACILITY NUMBER: 310311880

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/03/2024
Section Cited
CCR
87465(a)(4)

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(4) The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidenced by: Resident R1 has a prescription for a nutritional supplement. Prescription specifies 1 tablet per day. However, the actual bottle of supplement does not have a dosage listed.
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The facility will follow up with doctor and pharmacist to ensure that a label is obtained for the supplement from the pharmacy that lists all required information, including dose.

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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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024
LIC809 (FAS) - (06/04)
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