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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 310311880
Report Date: 10/24/2024
Date Signed: 10/24/2024 01:45:57 PM


Document Has Been Signed on 10/24/2024 01:45 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:
10/24/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Tito Andrada and Tito Andrada, Jr.TIME COMPLETED:
02:00 PM
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On 10-24-2024 LPA Tryon visited the facility to follow up on a visit and subsequent Facility Action Report by Alta Regional Center signed 10/21/24. The report states that the facility failed to complete daily MARS from October 1 to October 4, 2024. They also stated there were chairs in front of a resident door. LPA spoke with staff who was in the home at the time. She said that there was a chair against the wall in the resident's room that she uses to help the resident sit in the room when needed, but it was not in the doorway, simply side of the door.

The Regional Center issued a FAR with a Corrective Action Plan to do a training for all staff and residents in Client Rights; and for the facility to a double-check system for medication records to ensure that all meds are being given and that staff signs the MAR.

LPA reviewed resident MARS and found that they have been completed at this time; and the home is using a double-check system by having a second staff present when medications are given; and that staff also initials the MAR. Administrator said that staff had forgotten or not had time to initial boxes on the MAR; but that all medication had in fact been given to the residents. At this time, all initials have been added and plan continues.

At this time, LPA is issuing a Technical Violation for record keeping regarding the Medication MARS.

No deficiency was issued today.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024
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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