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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606341
Report Date: 08/06/2024
Date Signed: 08/06/2024 10:46:59 AM


Document Has Been Signed on 08/06/2024 10:46 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
N LA & CEN COA AC/SC, 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: 3DATE:
08/06/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Rody Espino- AdministratorTIME COMPLETED:
10:35 AM
NARRATIVE
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An Informal Conference was conducted today in the Woodland Hills Adult and Senior Care Regional office. The purpose of this Informal Conference is to discuss the incident that occurred during 2020

Present at today's meeting are the following:
· Eva Miller, Licensing Program Manager (LPM)
· Mariana Agban, Licensing Program Analyst (LPA)
· Rody Espino – Administrator

The informal conference process was explained to the Licensee. The Licensee was also informed that this Informal Conference is a part of the administrative action process. Further citations may result in a Non-Compliance Conference, which could lead to a referral to the Department's Legal Division for possible license revocation or other administrative actions.



BRIEF HISTORY: The facility has been in operation since licensure on 08/30/2005 and is licensed for six non-ambulatory residents, hospice waiver for 1.

On 09/14/23 LPA Agban conducted an annual Required visit and inspection of the facility. LPA also observed a room outside in the backyard next to the pool that has a hospital bed and a private bathroom. This room was not indicated on the facility sketch as a resident room. LPA also observed that the garage had been converted to a room with a private bathroom. A review of facility sketch does not indicate that there is a room created in the garage. Interview with the administrator revealed that the room was built during COVID-19 for staff for isolation in case of contact. During today’s meeting, LPA cited the facility on CCR section 87305 - Alterations to Existing Buildings or New Facilities (a)Prior to construction or alterations, all facilities shall obtain a building permit.


(Continue 809 C)
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: LILY OF THE VALLEY
FACILITY NUMBER: 197606341
VISIT DATE: 08/06/2024
NARRATIVE
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LPM Miller discussed and expressed concerns regarding adding additional rooms to the property without notifying CCL. LPM Miller also emphasizes the importance of properly reporting any changes or incidents occurring in the facility.


The Licensee was informed that Community Care Licensing (CCL) shall continue to frequently monitor the facility as often as necessary to ensure the Licensee's compliance with Title 22 Regulations

Exit interview conducted, and a copy of the report was given.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/06/2024 10:47 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
N LA & CEN COA AC/SC, 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: 08/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/06/2024
Section Cited
CCR
87305(a)

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87305 - Alterations to Existing Buildings or New Facilities (a)Prior to construction or alterations, all facilities shall obtain a building permit.
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The licensee agreed to obtain permits and proper inspections from the city. The licensee will email all necessary documents to the LPA by the POC date.
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Based on LPA's observation on 09/14/2023 and information obtained the Licensee had converted the garage to a room with a private bathroom without obtaining permits. This poses potential risk to the personal rights of the residents in care
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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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024
LIC809 (FAS) - (06/04)
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