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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 310311880
Report Date: 02/13/2025
Date Signed: 02/14/2025 11:30:33 AM

Document Has Been Signed on 02/14/2025 11:30 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:VILLAGE LANE RESIDENCEFACILITY NUMBER:
310311880
ADMINISTRATOR/
DIRECTOR:
ANDRADA, TITOFACILITY TYPE:
740
ADDRESS:155 VILLAGE LANETELEPHONE:
(530) 823-6335
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY: 6CENSUS: 6DATE:
02/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Tito AndradaTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 2/13/25 LPA Tryon visited the facility to conduct an annual visit. LPA met with licensee Tito Andrada and Administrator Tito Andrada Jr.
The facility currently has 6 residents.
LPA toured the facility including common areas, kitchen, dining area, food storage, medication storage, hallway, bedrooms, bathrooms, yard. the home is clean and nicely furnished. No hazards were noted. Food supplies appear more than adequate to meet the requirement of 2 days perishable and 7 days non-perishable. Foods are varied and appear to be fresh. Medications are centrally stored and locked. Smoke detectors installed, carbon monoxide detector, and fire extinguishers. Fire Extinguishers are charged and were checked recently.

LPA reviewed the CARE Tool with staff, interviewed staff and a resident. LPA reviewed 3 staff files and 2 of 6 resident files. Training appears to be up to date. CPR/First Aid is current for all staff. Administrator certifications are current. All staff have fingerprint clearance.

Client files are updated, include updated physician reports, admission agreements, etc.

At this time the facility appears to be in substantial compliance with the regulations. No deficiencies were cited. Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025
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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