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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201093
Report Date: 09/13/2023
Date Signed: 09/13/2023 03:07:53 PM

Document Has Been Signed on 09/13/2023 03:07 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:
09/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Cassandra Curry, AdministratorTIME COMPLETED:
03:20 PM
NARRATIVE
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On 9/13/2023 at 9:40AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Administrator, Cassandra Curry and informed her the reason for the visit. The facility’s fire clearance was approved for 6 ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Smoke and carbon monoxide combination detectors were observed. Fire extinguishers were observed to be full and last serviced on 5/23/2023. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 107.7 degrees F in the hallway bathroom. LPA observed grab bars and non-skid mat in the bathrooms. First Aid kit is complete. No bodies of water observed. Indoor and outdoor passageways were free of obstruction.

LPA reviewed 3 client and 3 staff files starting at 10:15AM. LPA reviewed a sample of client's medications starting at 1:45PM. LPA interviewed 2 clients and 2 staff starting at 1:20PM.

At 11:00AM, LPA observed C2's medical assessment stated C2 had two different ambulatory status.

At 11:10AM, LPA observed facility does not have functional capability assessment completed for all clients.

At 2:00PM, LPA observed facility was preparing client's medications a week in advance and out it it's original medication containers.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights were provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 09/13/2023 03:07 PM - It Cannot Be Edited


Created By: Grace Luk On 09/13/2023 at 02:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LILY HOUSE
FACILITY NUMBER: 019201093

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(c)(4)
Client Medical Assessments
(c) The medical assessment shall include the following: (4) A determination of the client's ambulatory status, as defined by Section 80001(n)(2).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by having two different ambulatory status on C2's medical assessment which poses a potential health and safety risk to persons in care.
POC Due Date: 10/06/2023
Plan of Correction
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Administrator has agreed to obtain a new medical assessment with one ambulatory status for C2 and submit a copy to CCLD by POC date.
Type B
Section Cited
CCR
80069.2(b)
Functional Capabilities Assessment
(b) Assessment of the client's need for assistance shall include consideration of his/her physical condition affecting participation in his/her own care, including:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having functional capability assessment completed for clients which poses a potential health and safety risk to persons in care.
POC Due Date: 10/06/2023
Plan of Correction
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Administrator has agreed to complete functional capability assessment for all clients and submit copies to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/13/2023 03:07 PM - It Cannot Be Edited


Created By: Grace Luk On 09/13/2023 at 02:53 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LILY HOUSE
FACILITY NUMBER: 019201093

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(5)
(k) The following requirements shall apply to medications which are centrally stored:

(5) Each client's medication shall be stored in its originally received container.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above by preparing client's medications a week in advance which poses a potential health and safety risk to persons in care.
POC Due Date: 10/06/2023
Plan of Correction
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Administrator has agreed to re-train all staff on medication administration and submit staff sign in sheet to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023


LIC809 (FAS) - (06/04)
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