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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005393
Report Date: 08/23/2023
Date Signed: 09/12/2023 05:03:10 PM


Document Has Been Signed on 09/12/2023 05:03 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:MEMORY LANE MANORFACILITY NUMBER:
507005393
ADMINISTRATOR:HOZAN-FARCAS, CONSUELAFACILITY TYPE:
740
ADDRESS:420 CORAL WOOD ROADTELEPHONE:
2095792337
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:5CENSUS: 0DATE:
08/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Consuela Hozan-FarcasTIME COMPLETED:
04:30 PM
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An unannounced annual inspection was completed by Licensing Program Analysts (LPAs) Kimberly Viarella and Arielle Pascua on 08/23/2023. LPAs identified themselves and the purpose of their visit to the Licensee, Consuela Hozan-Farcas. A brief interview followed. Census at the time was 0.

The following Technical Assistance was provided during today's inspection. These concerns must be addressed and Licensing must be contacted for an additional inspection prior to the admittance of any residents.

If Licensing is not informed, and the inspection is not completed prior to admitting any residents into care, Administrative Actions may be taken.
  • All toxins shall be locked and inaccessible to residents in care.
  • All prescription medications shall be locked and inaccessible to residents in care. Expiration dates shall be checked periodically and disposed appropriately.
  • All resident accommodations shall include the required furniture: chest of drawers, bed, night stand, lamp/lighting sufficient for reading, and a chair.
  • The facility shall be in good repair and all debris, broken appliances, furniture, medical equipment, bins, trash, suitcases, and other discarded items shall be removed from the facility's property.
  • The Licensee shall remove the dried vegetation, weeds, and animal feces.
  • The following shall be posted and visible to residents in care: the facility License, the Administrator's Certificate, the Emergency/Disaster Plan with facility sketch, and the poster of Resident Rights.
  • The Licensee shall also post a calendar of activities menus for the residents in care.
  • The Licensee shall repair/replace any missing window screens or screens with holes.
  • All food items in the refrigerator, freezer, and pantry will be inspected and all expired items shall be disposed.
  • Going forward, any food item once opened shall be dated appropriately as will any leftovers.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: MEMORY LANE MANOR
FACILITY NUMBER: 507005393
VISIT DATE: 08/23/2023
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  • The Licensee will submit the documentation to be associated to this facility.
  • There shall be a designated space for personal items, for example, a change of clothes, handbags, coats, meals, medications, etc. Personal items shall not be stored in multiple bedrooms, drawers, or closets.

There were no citations given today.



A copy of this report was provided to the Licensee.

Exit interview.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023
LIC809 (FAS) - (06/04)
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