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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 310311880
Report Date: 07/10/2025
Date Signed: 07/10/2025 04:01:33 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/03/2025 and conducted by Evaluator Todd Tryon
COMPLAINT CONTROL NUMBER: 59-AS-20250703083836
FACILITY NAME:VILLAGE LANE RESIDENCEFACILITY NUMBER:
310311880
ADMINISTRATOR:ANDRADA, TITOFACILITY TYPE:
740
ADDRESS:155 VILLAGE LANETELEPHONE:
(530) 823-6335
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:6CENSUS: 3DATE:
07/10/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:TIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Unlawful eviction
INVESTIGATION FINDINGS:
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On 7/10/2025 LPA visited the facility unannounced to open the complaint. LPA met with licensee Tito Andrada and Tito Andrada, Jr. LPA and staff discussed the situation. Resident R1 had lived in the facility for many years. Recently R1 suffered a medical emergency and was sent to the ER. Subsequently, it was decided the resident would need to be on hospice services. Since the facility does not have a hospice waiver, the Responsible Party for R1 was told R1 could not return to the facility on hospice, and the home cannot care for R1. The home does not wish to pursue requesting a hospice waiver at this time. CCL cannot force a facility to request a hospice waiver, especially if the facility does not feel this is a service that they could adequately provide for the safety and well-being of a resident. However, since R1 was deemed ready for discharge from the hospital, and the facility did say they could not take R1 back, a proper eviction notice was technically not given. Therefore, the allegation is Substaniated. A finding of Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. A deficiency is issued as per Title 22 Regulations and the Health and Safety Code. Appeal Rights were provided, exit interview conducted.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 59-AS-20250703083836
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: VILLAGE LANE RESIDENCE
FACILITY NUMBER: 310311880
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/08/2025
Section Cited
CCR
87224(a)(4)
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(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5).... Through interview and review of records it was learned that the home did not
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The home will submit a written plan of how such situations will be handled in the future should a resident be in a similar situation. Plan to be submitted to CCL by POC dated of 8/8/2025.
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issue a 30-day written notice before refusing to take R1 back into the home.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2