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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 310311880
Report Date: 12/28/2023
Date Signed: 12/28/2023 03:46:08 PM


Document Has Been Signed on 12/28/2023 03:46 PM - 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:
12/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Tito Andrada, Licensee and Tito Andrada, Jr.TIME COMPLETED:
04:30 PM
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On 12/28/2023 LPA Tryon visited the facility to conduct an annual visit. LPA met with licensee Tito Andrada and Administrator Tito Andrada Jr.
The facility currently has 6 residents.
LPA toured the facility including common areas, kitchen, dining area, food storage, medication storage, hallway, bedrooms, bathrooms, yard. the home is clean and nicely furnished. No hazards were noted. Food supplies appear more than adequate to meet the requirement of 2 days perishable and 7 days non-perishable. Foods are varied and appear to be fresh. Medications are centrally stored and locked. Smoke detectors installed, carbon monoxide detector, and fire extinguishers. Fire Extinguishers are charged and were checked in October 2023.

LPA reviewed the CARE Tool with staff, interviewed staff and a resident. LPA reviewed 4 of 5 staff files and 2 of 6 resident files. Training appears to be up to date. CPR/First Aid is current for all staff. Administrator certifications are current. All staff have fingerprint clearance.

Client files are updated, include updated physician reports, admission agreements, etc.

At this time the facility appears to be in substantial compliance with the regulations. No deficiencies were cited. Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023
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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