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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 374700335
Report Date: 04/08/2025
Date Signed: 04/08/2025 05:27:55 PM

Document Has Been Signed on 04/08/2025 05:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

HOME CARE ORGANIZATION EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
HOME CARE SERVICES, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
FACILITY NAME:MEMORY LANE, LLCFACILITY NUMBER:
374700335
ADMINISTRATOR/
DIRECTOR:		AMY M. WOMBOLTFACILITY TYPE:
300
ADDRESS:1642 LISA AVE.TELEPHONE:
(760) 536-3139
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY: CENSUS: DATE:
04/08/2025
Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Amy WomboltTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
NARRATIVE
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On April 8 2025, Home Care Services Bureau (HCSB) Enforcement Analyst (EA), Adrian Mangina arrived at the business office of Memory Lane LLC for a Post Licensing inspection. Upon arrival, Enforcement Analyst was granted entry to the premises by Designee Michelle Cosper. Stephanie Verduzco, Home Care Aide and Administrator was also present. Owner Amy Wombolt arrived a short time later. Analyst Mangina observed the proper posting of business hours and License. The Analyst was provided an area in which the review of personnel and administrative files could be performed. Designee provided Analyst with proof of current professional liability policy, worker's compensation, and dishonesty bond. Ten employee files were reviewed.

Upon completion of the file review the analyst discussed the findings of the inspection with Ms. Wombolt. The Analyst informed the representative named above of the deficiencies found and explained they would be noted on the HCS809-D forms. In addition, the Licensee was provided a copy of the HCS9058 Appeal Rights form.

NAME OF LICENSING PROGRAM ANALYST: Adrian L Mangina
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

HCS809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 04/08/2025 05:27 PM - It Cannot Be Edited


Created By: Adrian L Mangina On 04/08/2025 at 04:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

HOME CARE ORGANIZATION EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
Although this visit/inspection may have focused on the review of specific licensing requirements, the applicant/licensee must comply with all applicable requirements. The California Department of Social Services retains authority to issue citations or take disciplinary action for any deficiency.


FACILITY NAME: MEMORY LANE, LLC
FACILITY NUMBER: 374700335

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/09/2025
Section Cited
1796.44(b)(2)
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TRAINING REQUIREMENTS:(b) An affiliated home care aide shall complete a minimum of five hours of entry-level training prior to presence with a client, as follows: three hours of safety training, including basic safety precautions, emergency procedures, and infection control.
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This requirement was not met as evidenced by: During the review of files on 4/8/25 Licensee was not able to provide at time of inspection proof that Reference #2, completed 2 of 3 hours entry-level training including basic safety precautions and infection control and Reference #4, #5, and #7, completed 1 of 3 hours entry-level training including basic safety precaution a finding which poses an immediate health and safety risk to persons in care.
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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.
LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2025
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/08/2025 05:27 PM - It Cannot Be Edited


Created By: Adrian L Mangina On 04/08/2025 at 04:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

HOME CARE ORGANIZATION EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
Although this visit/inspection may have focused on the review of specific licensing requirements, the applicant/licensee must comply with all applicable requirements. The California Department of Social Services retains authority to issue citations or take disciplinary action for any deficiency.


FACILITY NAME: MEMORY LANE, LLC
FACILITY NUMBER: 374700335

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/29/2025
Section Cited
1796.44(c)
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TRAINING REQUIREMENTS: In addition to the requirements in subdivision (b), an affiliated home care aide shall complete a minimum of five hours of annual training. The annual training shall relate to core competencies and be population specific, which shall include, but not be limited to, the following areas: Clients’ rights and safety, How to provide for, and respond to, a client’s daily living needs, How to report, prevent, and detect abuse and neglect., How to assist a client with personal hygiene and other home care services, If transportation services are provided, how to safely transport a client.
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This requirement was not met as evidenced by: During the review of files on 4/8/25 Licensee was not able to provide proof that Reference #2 has completed 5 of 5 hours of required hours annual training at time of inspection including: Clients’ rights and safety, How to provide for, and respond to, a client’s daily living needs, How to report, prevent, and detect abuse and neglect, How to assist a client with personal hygiene and other home care service, and If transportation services are provided, how to safely transport a client, and reference #6 has completed Clients’ rights and safety, How to report, prevent, and detect abuse and neglect, How to assist a client with personal hygiene and other home care services, a finding which poses a potential health and safety risk to persons in care,
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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.
LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2025
LIC809 (FAS) - (06/04)
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