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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201093
Report Date: 10/21/2024
Date Signed: 10/21/2024 03:08:30 PM

Document Has Been Signed on 10/21/2024 03:08 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/
DIRECTOR:		CURRY, CASSANDRA B.FACILITY TYPE:
735
ADDRESS:4355 COLGATE WAYTELEPHONE:
(925) 493-7968
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 6CENSUS: 6DATE:
10/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Cassandra Curry, Administrator
Corina Grajeda, Caregiver		TIME VISIT/
INSPECTION COMPLETED:
03:25 PM
NARRATIVE
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On 10/21/2024 at 2:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management inspection in regards to incident report received on 10/17/2024. LPA met with Administrator, Cassandra Curry and caregiver, Corina Grajeda.

Incident report dated 10/17/2024 revealed that staff (S1) observed client (C1) was not at the facility. When S1 made rounds to check on clients around 5:10AM, all clients including C1 was in their rooms. S1 checked all exit doors and observed C1 may have left from the sliding glass door in the garage as it was unlocked. S1 drove around to look for C1 and then called 911. C1's family and doctor was notified. C1 was found and brought back by the police.

Interview with staff revealed that C1 did not exhibit wandering behavior prior and this was the first time C1 wandered from the facility.

During record review, LPA observed that physician's report dated 10/1/2024 stated that C1 cannot leave the facility unassisted.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalty.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2024
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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Document Has Been Signed on 10/21/2024 03:08 PM - It Cannot Be Edited


Created By: Grace Luk On 10/21/2024 at 02:45 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: 10/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2024
Section Cited
CCR
80078(a)

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Responsibility for Providing Care and Supervision. The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met as evidence by:
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Facility have scheduled an appointment with the doctor this week and will create a new needs and service plan for the client to address wandering.
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Based on record review, licensee did not comply with the section cited above by having a client left the facility unassisted which poses a potential health and safety risk to the persons in care.
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Administrator will submit a copy of the LIC625 to CCLD by POC date.

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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: 10/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2024


LIC809 (FAS) - (06/04)
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