507005393-9-15-2023-27-AS-KVIA-CVPUB9-20230915152559

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507005393
Report Date: 09/15/2023
Date Signed: 09/15/2023 03:27:33 PM

Document Has Been Signed on 09/15/2023 03:27 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 MANOR		FACILITY NUMBER:	507005393
ADMINISTRATOR:	HOZAN-FARCAS, CONSUELA		FACILITY TYPE:	740
ADDRESS:	420 CORAL WOOD ROAD		TELEPHONE:	(209) 579-2337
CITY:	MODESTO	STATE: CA	ZIP CODE:	95356
CAPACITY:	5	CENSUS:	DATE:	09/15/2023
TYPE OF VISIT:	Office	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Consuela Hozan-Farcas		TIME COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	A Non-Compliance Conference (NCC) was conducted on this day, 09/22/2023, by the Sacramento South Regional Office via Microsoft Teams meeting. The purpose of this Non-Compliance Conference meeting was to discuss the deficiencies at Memory Lane Manor, the status of its license and ways to bring it back into compliance and avoid legal action. The focus of this meeting will be to discuss Memory Lane Manor’s change of status from a sole proprietorship to an LLC. This was completed on February 9, 2022 and would have required that the Licensee contact the Centralized Applications Bureau to apply for a new license. The other issue being discussed today is that the Licensee/Administrator is not listed as Associated to the facility. Present at the meeting were Licensing Program Manager (LPM) Liza King and Licensing Program Analysts (LPAs), Kimberly Viarella, Maja Jensen and Arielle Pascua. Representing Memory Lane Manor was Consuela Hozan-Farcas. The Non-Compliance Conference process was explained during this meeting to include the Administrative Process. The focus of the concerns at this time: · Status of Memory Lane Manor’s License o Sole Proprietorship vs LLC · Criminal background check for Licensee/Administrator · Deficiencies observed during annual inspection on 08/23/23 Licensee agreed to do the following in order to bring the facility into compliance no later than the following dates:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: 09/15/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Licensee will: apply for a Change of Ownership, dissolve the LLC, remain a sole proprietorship, or forfeit the license, within 7 days (09/22/2023).

Licensee will notify CCL which action will be taken by Wednesday, 09/20/2023.

A follow-up MicrosoftTeams conference will be conducted on Monday, September 25 to discuss the steps moving forward and the association of the Administrator to the facility.

Exit interview conducted via telephone, and copy of report provided by email.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2