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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600903
Report Date: 10/11/2024
Date Signed: 10/11/2024 11:46:16 AM


Document Has Been Signed on 10/11/2024 11:46 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:VILLAGE LANE HOMEFACILITY NUMBER:
415600903
ADMINISTRATOR:ALYSSA JOY DECANOFACILITY TYPE:
740
ADDRESS:209 VILLAGE LANETELEPHONE:
(650) 993-8952
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY:4CENSUS: 3DATE:
10/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Joy DecanoTIME COMPLETED:
12:00 PM
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On October 11, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Administrator, Alyssa Joy Decano and Licensee, William Narciso explained the purpose of the visit.

LPAs toured the facility inside and outside including all of resident rooms, common areas & kitchen. The indoor and outdoor passageways were free of obstruction. No accessible bodies of water of fire safety hazards observed. Living room and dining room was observed to be clean, free from tripping hazards and odor-free. A comfortable temperature is maintained and lighting is sufficient for comfort. LPA toured kitchen and observed two day perishable and seven day non-perishables. Sharps, chemicals and medications were observed to be locked an inaccessible to residents.

LPAs observed four resident bedrooms; all of which are private rooms. All rooms were observed to be clean, in good repair with required furniture. One full bathroom and one half bathroom was observed to be clean and odor-free. Water temperature throughout the facility measured at 107 degrees F.

Garage was toured, washer and dryer were observed to be in good repair. Carbon monoxide monitor is working properly. All fire extinguishers have been checked and current as of May 2024. Emergency drills are logged and done monthly.

LPAs reviewed 3 resident records and 4 staff records. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirement. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

No citations are issued during the visit. LPA reviewed report with administrator and a copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 629-4305
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2024
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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