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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 310311880
Report Date: 10/09/2025
Date Signed: 10/09/2025 10:41:13 AM

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
04/25/2025 and conducted by Evaluator Ivan Avila
COMPLAINT CONTROL NUMBER: 59-AS-20250425140320
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:
10/09/2025
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Tito AndradaTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility staff failed to report unexplained injuries and bruising
Facility staff did not provide timely medical care
Facility staff did not allow resident return following hospital discharge
INVESTIGATION FINDINGS:
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On October 9, 2025, Licensing Program Analysts (LPAs) Ivan Avila and Cassandra Mikkelson conducted an unannounced complaint investigation visit regarding the above allegations directed by the Department. LPA Avila met with licensee Tito Andrada and Administrator Tito Andrada, Jr. and explained the purpose of the visit.

During the investigation process, interviews and a review of records were initiated.

LPA investigated the allegation, “Facility staff failed to report unexplained injuries and bruising.” Based on documentation provided, it was noted that R1 sustained several falls that were not reported as required. The administrator and licensee gave conflicting and inaccurate accounts of an incident that occurred on April 19, 2025. R1 suffered two falls that same day but only one was reported. Facility records reviewed by LPA did not include corresponding incident reports for these falls, leaving no documented trail of injuries or facility actions taken.
------Continued on LIC9099C------
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Ivan Avila
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
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 4
Control Number 59-AS-20250425140320
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
VISIT DATE: 10/09/2025
NARRATIVE
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LPA investigated the allegation, “Facility staff did not provide timely medical care.” Based on interviews and documentation provided, on April 19,2025, R1 sustained a fall and licensee stated staff were instructed to call 911 within minutes. However, the incident report submitted to LPA recorded conflicting information. R1 fell in the bedroom, not in the activity area and R1 complained of knee pain. Documentation revealed that medical attention was not called for more than one hour after the fall. The inconsistencies between the licensee’s oral statements and the written reports demonstrated inaccurate documentation and delayed medical intervention.

LPA investigated the allegation, “Facility staff did not allow resident return following hospital discharge.” Based on interviews and documentation provided, on April 23, 2025, R1 was medically cleared for discharge from the hospital and approved for home health services. Based on records reviewed, it was confirmed that R1 was fit to return to the facility. During an interview, licensee noted that R1 was never told that they could not return but stated based on their observation of R1 it was determined that R1’s level of care was beyond what the facility could provide. The facility’s decision to deny reentry, despite medical clearance, constituted an unlawful eviction. The violation will result in a Repeat Violation. An Immediate Civil Penalty will be issued.

Based on LPAs observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, and the California Health and Safety Code are cited on the attached LIC9099-D.

An exit interview was conducted, and a copy of the report and appeal rights were provided.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Ivan Avila
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 59-AS-20250425140320
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: 10/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/17/2025
Section Cited
CCR
87224(a)(4)
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87224(a)(4) 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.... the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident. This requirement is not met as evidence by:
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Licensee will delevop a procedure to address resident eviction procedures. POC will be emailed to LPA by 10/17/2025.
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Based on the investigation, refusal to allow R1 to return back to the facility following a discharge which constitutes an unlawful eviction, which poses a potential health, safety, and personal rights violation to the residents in care.
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Immediate Civil Penalty of $1,000 is assessed for a Repeat Violation within a 12-month period.
Type B
10/17/2025
Section Cited
CCR
87211(a)(1)(B)
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87211(a)(1)(B) Each licensee shall furnish to the licensing agency such reports as the Department may require, including…This report shall include the resident's name, age, sex and date of admission; date and nature of event… Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement is not met as evidence by:
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Licensee will submit a statement of understanding of regulation 87211(a)(1)(B). Licensee will email statement to LPA by POC due date 10/17/2025.
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Based on interviews and records reviewed, the facility did not report unexplained injury and bruising after R1’s fall, which poses a potential health, safety, and personal rights violation to the residents in care.
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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: Anthony Perez
LICENSING EVALUATOR NAME: Ivan Avila
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 59-AS-20250425140320
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: 10/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/17/2025
Section Cited
CCR
87465(g)
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87465(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical....Sections 87469(c)(2), (c)(3), or (c)(4). This requirement is not met as evidence by:
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Licensee will submit a statement of understanding of regulation 87465(g). Licensee will email statement to LPA by POC due date 10/17/2025.
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Based on the investigation, staff did not provide timely medical care to R1 following a fall, which poses a potential health, safety, and personal rights violation to residents in care.
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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: Anthony Perez
LICENSING EVALUATOR NAME: Ivan Avila
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4