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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 10:45:12 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-20250425103010
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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Staff do not follow reporting requirements
Staff did not safeguard resident's P & I funds
INVESTIGATION FINDINGS:
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On October 9, 2025, Licensing Program Analysts (LPAs) Ivan Avila and Cassandra Milkenson 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, “Staff do not follow reporting requirements.” Based on documentation provided, it was noted that R1 sustained several falls that were not reported as required. Facility records reviewed by LPA did not include corresponding incident reports for these falls, leaving no documented incident reports submitted to the Department. The following allegation cited above is substantiated, but no deficiency will be issued as LPA substantiated the similar allegation for Complaint #59-AS-20250425140320 on October 9, 2025.
------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 5
Control Number 59-AS-20250425103010
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, “Staff did not safeguard resident’s P & I funds.” Based on record review, interviews, it was documented that R1’s funds were used to purchase items such as cable connection, pharmacy co-pays, body wash, and coloring books for in-home activities. A wheelchair was purchased using R1’s P&I funds on November 19, 2025. Resident cash resources entrusted to the licensee for safekeeping must not be commingled with or used as facility funds. The use of R1’s P&I funds for the purchase of durable medical equipment (a wheelchair) constitutes misuse of resident cash resources. The wheelchair is a facility responsibility under the provision of care and services and should not have been purchased using R1’s personal money. By using resident funds for this purpose, the facility failed to safeguard R1’s personal property.

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 5
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-20250425103010

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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Staff did not adequately address a change in resident's condition
Staff do not treat client with dignity or respect
Staff do not follow resident's needs and services plan
Staff do not keep clients authorized person informed about client's care
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, “Staff did not adequately address a change in resident’s condition.” Based on documentation provided, medical assistance had been sought out when facility staff found out about R1’s change in condition. Interviews indicated that facility policy is that when it is determined a resident needs emergency medical attention, the facility initiates emergency services. The Department was unable to determine through interviews and documentation if the facility failed to adequately address R1’s change of condition.
------Continued on LIC9099C------
Unsubstantiated
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: 3 of 5
Control Number 59-AS-20250425103010
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, “Staff do not treat client with dignity or respect.” Based on interviews conducted, staff conduct emergency drills to simulate real life disasters which require all residents to evacuate the facility. During the drills staff knock on residents’ doors and help escort them out of the facility. Residents would get frustrated and impatient during the drills that cause them to yell at R1. Staff indicated they would intervein and de-escalate the situation and make sure all residents were safe. Staff have timely addressed resident altercations and treat all residents with respect.

LPA investigated the allegation, “Staff do not follow resident’s needs and service plan.” Based on documentation, and interviews conducted, evidence was not found to support that staff do not follow R1’s needs and service plan. Documentation reviewed by LPA indicated that staff meet the needs and care plan for all residents. LPA could not corroborate the allegation.

LPA investigated the allegation, “Staff do not keep clients authorized person informed about client’s care.” Based on interviews conducted, facility staff stated they have called R1’s authorized person by phone or email each time an incident or event happened regarding R1’s care. Interviews indicated that facility staff and authorized person for R1 have had communication but have a rough relationship causing tension between both parties. This has caused a lot of misunderstandings and lack of communication at times. LPA could not corroborate the allegation.

Based on interviews conducted and observations, the preponderance of evidence standards has not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. Findings that the complaint is Unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted, and a copy of the report was 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: 4 of 5
Control Number 59-AS-20250425103010
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
87217(e)
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87217(e) Cash resources and valuables of residents which are handled by the licensee for safekeeping shall not be commingled with or used as the facility funds or petty cash, and shall be separate...facility’s funds and valuables. This requirement is not met as evidence by:
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Licensee submit a statement of understanding of regulation 87217(e). Statement will be emailed to LPA by POC due date 10/17/2025.
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Based on record review and interview, the licensee failed to safeguard R1’s cash resources by purchasing a new wheelchair which constitutes misuse of resident cash resources, which poses an immediate 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: 5 of 5