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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201093
Report Date: 09/01/2021
Date Signed: 09/01/2021 07:06:37 PM

Document Has Been Signed on 09/01/2021 07:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:LILY HOUSEFACILITY NUMBER:
019201093
ADMINISTRATOR:CURRY, CASSANDRA B.FACILITY TYPE:
735
ADDRESS:4355 COLGATE WAYTELEPHONE:
(925) 493-7968
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 6CENSUS: 6DATE:
09/01/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Cassandra Curry, AdministratorTIME COMPLETED:
05:00 PM
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On 9/1/2021 at 1:45PM, Licensing Program Analysts (LPAs) G. Luk and L. Holmes arrived unannounced to conduct a Pre-Licensing inspection. LPAs met with Administrator, Cassandra Curry. The facility's fire clearance was approved for 6 ambulatory clients.

LPAs toured facility with administrator including but not limited to client's bedrooms, bathrooms, living room, kitchen, and outdoor area. Client's rooms were fully furnished and clean. Hot water was measured at 105 degrees F. LPAs observed lighting in all rooms. LPAs observed facility had a 7-day of non-perishable and 2-day of perishable food supply. Medications were locked in the hallway closet. Combination Smoke and Carbon Monoxide detectors were observed. First aid kit was complete. Indoor and outdoor passageways were free of obstruction. Fire extinguisher was observed to be full and last serviced on 4/19/2021. Emergency disaster plan was complete.

The following will need to be completed before recommending licensure to Centralized Application Bureau (CAB):

1. LPAs observed air vent in kitchen floor near stairs was lifted and not flushed to the floor. It's a trip hazard to clients and visitors. Administrator stated that property owner is aware and will be repaired soon.

2. LPAs observed unlocked lighter, scissors, and cleaning supplies. Staff locked up items during inspection.

3. S1 and S2 did not have current first aid training completed.

4. C4, C5, and C6 does not have current needs and service plans on file.

(Continue on LIC809C...)

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: LILY HOUSE
FACILITY NUMBER: 019201093
VISIT DATE: 09/01/2021
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5. Facility did not have emergency plan that included self-reliant 72 hours plan, identifying transportation needs, etc. This information can be found on LIC610E which facility did not have included in their emergency disaster plan.

Licensee/applicant will submit proof of corrections to CCL on/before 9/27/2021.



LPAs waived Component III as Administrator have been in this position for over 9 years. LPAs provided a copy of the Component III for Administrator to review.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
LIC809 (FAS) - (06/04)
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