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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005393
Report Date: 08/28/2024
Date Signed: 08/28/2024 02:12:49 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/28/2024 02:12 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:MEMORY LANE MANORFACILITY NUMBER:
507005393
ADMINISTRATOR:HOZAN-FARCAS, CONSUELAFACILITY TYPE:
740
ADDRESS:420 CORAL WOOD ROADTELEPHONE:
(209) 579-2337
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:5CENSUS: DATE:
08/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Consuela Hozan-FarcasTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Maja Jensen spoke to Licensee by telephone today. Licensee, Consuela Hozan-Farcas, is requesting to initiate a temporary hold on the license. The Licensee confirmed that no residents have been accepted in to care.

The Licensee agreed to the following:

-annual fees will be kept current (your PIN was provided to you today)
-no residents will be accepted unless the Department has been notified prior to admission
-a mandatory reinspection must take place prior to accepting any residents
-Licensee will remain available to the Department for contact by phone or email

A copy of this report is being mailed to the Licensee with request for signature.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
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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