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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606341
Report Date: 08/26/2022
Date Signed: 08/26/2022 11:39:37 AM


Document Has Been Signed on 08/26/2022 11:39 AM - 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:LILY OF THE VALLEYFACILITY NUMBER:
197606341
ADMINISTRATOR:NATALIA L. ESPINOFACILITY TYPE:
740
ADDRESS:8618 BOTHWELL ROADTELEPHONE:
(818) 993-7800
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY:6CENSUS: 2DATE:
08/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Rudy & Natalia EspinoTIME COMPLETED:
11:45 PM
NARRATIVE
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On 8/26/22 at 10:10 a.m. Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA was greeted by staff member. LPA observed covid-19 signage, hand sanitizer and a visitor sign in log. Staff did not screen LPA for infection control protocols.

Staff contacted the Administrator and LPA met with the Administrators/Licensees at 11:00 a.m. The purpose of the visit was explained, and an entrance interview was conducted.

LPA initiated a physical plant tour at 10:45 a.m. This is a six (6) bedroom, three (3) bathroom Residential Care Facility for the Elderly. LPA was able to tour the home and did not observe any immediate health and safety concerns. Sufficient PPE supplies were observed. The fire extinguisher was observed in the kitchen area and has a date of purchase of 6/18/2022. Smoke detectors and carbon monoxide monitors were observed to be functional. Facility maintains a comfortable temperature of 79 degrees Fahrenheit. LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Sharps, cleaning supplies and medications are centrally stored and are kept locked in various kitchen cabinets and drawers. Extra towels and linens were readily available. There is a clean covered shaded area in the back yard and there is a pool which has a gate and is kept locked and inaccessible to residents in care.

Deficiencies issued per CA Code of Regulations Title 22 during today’s visit. Report was signed and delivered by Administrator/Licensee and an exit interview was conducted.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2022
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 08/26/2022 11:39 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: LILY OF THE VALLEY
FACILITY NUMBER: 197606341

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87470(c)(1)(F)
87470(c) Infection Control Requirements shall be developed by the licensee... (1) The Infection Control Plan shall include: (F) Staff shall demonstrate knowledge... appropriate to the job assigned and as evidenced by safe and effective job performance.

This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on observations the licensee/staff did not comply with the cited section by not screening LPA’s for symptoms of COVID 19 upon entry, which poses and immediate Health and Safety and personal rights risk to persons in care.
POC Due Date: 08/28/2022
Plan of Correction
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Licensee/Administrator will conduct in-house training regarding infection control. Administrator is to have a designated staff screening all visitors for Covid-19 upon arrival. Proof of training and designation of staff shall be emailed to LPA no later than 08/28/22.
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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2022
LIC809 (FAS) - (06/04)
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