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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610358
Report Date: 02/13/2023
Date Signed: 02/13/2023 04:11:23 PM

Document Has Been Signed on 02/13/2023 04:11 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:LILY & ROSE SENIOR LIVING INCFACILITY NUMBER:
197610358
ADMINISTRATOR:JOCOM, JOANNEFACILITY TYPE:
740
ADDRESS:287 VENTURA STREETTELEPHONE:
(714) 458-5508
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY: 6CENSUS: 5DATE:
02/13/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Joann JocomTIME COMPLETED:
04:15 PM
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At 10:00 am Licensing Program Analyst (LPA) Tihesha “Lynn” Smith conducted an announced pre-licensing visit with administrator. Identification of the Applicant/administrator was verified by photo ID.

The facility has a capacity of six (6). Application received for (1) Ambulatory and (5) Non-ambulatory- with bedrooms #2, #3, and #4 designated for Non-ambulatory residents.

Purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with the rules and regulations of California Code of Regulations, Title 22, Division 6.

Today's site visit consisted of LPA touring the physical plant inside and outside and observed the following:

The common areas (kitchen, living room, and dining areas) were appropriately furnished, and lighting was adequate. The facility has a variety of adequate perishable and non-perishable food supply. Appliances in the kitchen appeared to be functional. The living room has a television and comfortable furniture. The sharps are stored and locked in drawer in kitchen and under kitchen sink. Kitchen cleaning supplies, laundry detergents, and other toxins are stored in locked hallway closet.

Medications are stored in locked hallway closet on top shelves. Resident and staff records stored also stored in locked hallway closet. The first aid kit is readily available.

There is a functioning telephone/landline on the premises. An emergency exit plan/sketch is posted near each entrance/exit wall with other posting requirements.

There are four (4) resident bedrooms, designated as follows:

B1: Ambulatory/Private B2: Non ambulatory/Shared B3: Non-Ambulatory/Shared B4: Non-Ambulatory/Private. No room is designated for staff use. Resident bedrooms were observed to be appropriately furnished with a bed, nightstand, a chair. Extra linen stored in each resident room.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2023
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 2
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 & ROSE SENIOR LIVING INC
FACILITY NUMBER: 197610358
VISIT DATE: 02/13/2023
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(Cont from 809)
There are two (2) bathrooms in the facility: one (1) designated for residents and one (1) designated for staff. The hot water was tested for resident bathroom and measured 105.1 °F. The bathroom has non-skid mats, trash cans with lids and functional grab bars.

There are two (2) fire extinguishers: one (1) is located in the kitchen attached to wall and one (1) is located in hallway attached to the wall. Both Fire extinguishers observed to be fully charged and was purchased. Dual Smoke and Carbon Monoxide detectors were observed all over the facility, tested, and observed to be operational at approximately 1:20 pm.

There is a side covered patio for residents to conduct outdoor activities. There is a basement used for PPE/supplies storage locked and inaccessible to residents. The is no backyard. The garage is not attached to the house and is not part of the facility. There is no body of water on the facility. Facility appears to be clean and in good repair.

Component III was conducted with the administrator and administrator confirmed understanding of Title 22.

At time of visit this facility is not ready to be licensed. The following corrections must be made:

· Add the additional patio Entry/Exit door to Facility sketch

· Add basement door to facility sketch and Resubmit Facility sketch

· Update all posted facility sketches

This report will be forwarded to the Centralized Application Bureau (CAB).

Exit interview was conducted and a copy of this report was provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2023
LIC809 (FAS) - (06/04)
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