Village Lane Residence

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cassandra Mikkelson arrived unannounced and met with Administrator Tito Andrada to conduct an annual inspection utilizing the inspection tool. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed resident rooms, common area bathrooms, kitchen, common areas, and perimeter of care home. LPA observed rooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two day perishable and (7) seven day non-perishable food supply on hand. Smoke detectors and carbon monoxide detectors are operational in the care home. Fire extinguishers and first aid kit are maintained and ready for emergency use. LPA checked medication storage and found medications to be locked away and inaccessible to the residents. LPA reviewed three (3) resident files, two (2) staff files and resident medications. Facility has a current copy of certificate of liability insurance and LPA received a copy. As a result of this visit, no deficiencies were cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Exit interview was conducted with Administrator.the state’s words, verbatim · CDSS document, Feb 5, 2026

Allegation investigated: Staff do not follow reporting requirements Staff did not safeguard resident's P & I funds

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 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. 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.the state’s words, verbatim · CDSS document, Oct 9, 2025 · control 59-AS-20250425103010

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(e) · Plan of correction due date: Oct 17, 2025

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: 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.the state’s words, verbatim · CDSS document, Oct 9, 2025

Plan of correction: Licensee submit a statement of understanding of regulation 87217(e). Statement will be emailed to LPA by POC due date 10/17/2025.

Allegation investigated: 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

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 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.the state’s words, verbatim · CDSS document, Oct 9, 2025 · control 59-AS-20250425140320

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a)(4) · Plan of correction due date: Oct 17, 2025

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: 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.the state’s words, verbatim · CDSS document, Oct 9, 2025

Plan of correction: Licensee will delevop a procedure to address resident eviction procedures. POC will be emailed to LPA by 10/17/2025. Immediate Civil Penalty of $1,000 is assessed for a Repeat Violation within a 12-month period.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: Oct 17, 2025

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: 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.the state’s words, verbatim · CDSS document, Oct 9, 2025

Plan of correction: 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.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(g) · Plan of correction due date: Oct 17, 2025

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: 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.the state’s words, verbatim · CDSS document, Oct 9, 2025

Plan of correction: Licensee will submit a statement of understanding of regulation 87465(g). Licensee will email statement to LPA by POC due date 10/17/2025.

Allegation investigated: Unlawful eviction

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. Substantiatedthe state’s words, verbatim · CDSS document, Jul 10, 2025 · control 59-AS-20250703083836

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a)(4) · Plan of correction due date: Aug 8, 2025

(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 issue a 30-day written notice before refusing to take R1 back into the home.the state’s words, verbatim · CDSS document, Jul 10, 2025

Plan of correction: 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.

Type of visit: Required - 1 Year

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.the state’s words, verbatim · CDSS document, Feb 13, 2025

Type of visit: Case Management - Deficiencies

On 10-24-2024 LPA Tryon visited the facility to follow up on a visit and subsequent Facility Action Report by Alta Regional Center signed 10/21/24. The report states that the facility failed to complete daily MARS from October 1 to October 4, 2024. They also stated there were chairs in front of a resident door. LPA spoke with staff who was in the home at the time. She said that there was a chair against the wall in the resident's room that she uses to help the resident sit in the room when needed, but it was not in the doorway, simply side of the door. The Regional Center issued a FAR with a Corrective Action Plan to do a training for all staff and residents in Client Rights; and for the facility to a double-check system for medication records to ensure that all meds are being given and that staff signs the MAR. LPA reviewed resident MARS and found that they have been completed at this time; and the home is using a double-check system by having a second staff present when medications are given; and that staff also initials the MAR. Administrator said that staff had forgotten or not had time to initial boxes on the MAR; but that all medication had in fact been given to the residents. At this time, all initials have been added and plan continues. At this time, LPA is issuing a Technical Violation for record keeping regarding the Medication MARS. No deficiency was issued today. Exit interview conducted.the state’s words, verbatim · CDSS document, Oct 24, 2024

Type of visit: Case Management - Deficiencies

On May 2, 2024 LPA Tryon visited the facility to do a case management visit, to follow up on a recent visit from Alta California Regional Center during which several issues were noted. LPA met with Licensee Tito Andrada and Administrator Tito Andrada, Jr. During a Title 17 Review visit ACRC staff found that staff S1 was hired at the facility in 2021 and she did not have a TB clearance until March 2024. LPA reviewed documentation and spoke with licensee and Administrator, who confirmed that this is true. ACRC staff also noted that staff in the home did not have CEU Training during the calendar year 2023. LPA verified that staff did receive multiple hours of training in December 2022 and also in January 2024. However, training was not done in calendar year 2023. So, technically, the home did not meet the requirement of 20 hours ANNUAL training as per Health and Safety Code 1569.625. ACRC staff noted that a medication for resident R1 had a MAR medication sheet which listed that the resident should take 1 pill per day; but there was no specific dosage listed on the medication bottle. The following deficiencies were cited as per Title 22 Regulations and the Health and Safety Code. Exit interview conducted, appeal rights provided.the state’s words, verbatim · CDSS document, May 2, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(f) · Plan of correction due date: May 3, 2024

All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physical not more than six (6) months prior to or seven (7) days after employment or licensure. This requirement was not met as evidenced by: through review it was found that staff S1 was hired in 2021 and did not have a TB clearance until March 2024.the state’s words, verbatim · CDSS document, May 2, 2024

Plan of correction: The facility will ensure that in the future all staff have a physical exam and TB test as per regulation timelines. The facility has already obtained a physician report and TB clearnace for S1 at this time. POC is cleared.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.625 · Plan of correction due date: Jun 3, 2024

The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training...training requirements shall also include an additional 20 hours annually This regulation is not met as evidenced by: through record review it was found that staff at the facility received training in December 2022 and in January 2024, but technically did not receive any training in calendar year 2023.the state’s words, verbatim · CDSS document, May 2, 2024

Plan of correction: The facility will ensure that all staff meet the intial and ongoing training requirements as per regulation. Administrator will submit a plan of how he will ensure that all facility staff obtain required hours of training each year dating from their date of employment.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jun 3, 2024

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Resident R1 has a prescription for a nutritional supplement. Prescription specifies 1 tablet per day. However, the actual bottle of supplement does not have a dosage listed.the state’s words, verbatim · CDSS document, May 2, 2024

Plan of correction: The facility will follow up with doctor and pharmacist to ensure that a label is obtained for the supplement from the pharmacy that lists all required information, including dose.

Type of visit: Required - 1 Year

On 12/28/2023 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 in October 2023. LPA reviewed the CARE Tool with staff, interviewed staff and a resident. LPA reviewed 4 of 5 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.the state’s words, verbatim · CDSS document, Dec 28, 2023