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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320189
Report Date: 08/18/2021
Date Signed: 08/18/2021 06:18:54 PM

Document Has Been Signed on 08/18/2021 06:18 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, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:LILLY'S OPEN ARMS IVFACILITY NUMBER:
198320189
ADMINISTRATOR:JONES, LILLYFACILITY TYPE:
735
ADDRESS:719 W. ATHENS BLVDTELEPHONE:
(310) 684-9541
CITY:LOS ANGELESSTATE: CAZIP CODE:
90044
CAPACITY: 4CENSUS: 0DATE:
08/18/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Lilly JonesTIME COMPLETED:
03:30 PM
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Licensing Program Analysts (LPA) Jey Cardenas made an announced visit, and met with the Applicant Lilly Jones also present were Administrator, Devona Thomas and consultant, Daphne Howell and London Dirks to conduct a Pre-Licensing evaluation. An application was submitted to Community Care Licensing Department (CCLD) on 6/16/2021 for an initial application for Adult Residential for ages 18-59 years. The requested capacity is for four (4) ambulatory clients.

Structure: Facility is a one story family home with four (4) client bedrooms, three (3) full bathroom, Family room/ living room, dining area, kitchen, small office, and shaded patio area, car garage is located in the west side of the property. Washer/Dryer appliances are located in the laundry area near bathroom #2. The facility is gated. There are three (3) Exits located adjacent from kitchen, in the family room, and near bathroom#2. Front yard landscape is in good condition at time of visit. Bedroom Residents: Bedrooms #1-4 are equipped with one bed, night-stand, lamp/ overhead lightning, chair, and TV. Bedroom staff: No bedrooms are used for awake staff. Bathrooms: Bathrooms have a working toilet, wash basin, and shower/ bathtub. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress padding, fitted sheet, blanket and bedspreads. Emergency Phone Numbers, Exit Plan: Emergency numbers are posted and readily available for review . Facility has a land line telephone located near the entrance. Three (3) fully charged fire extinguishers are located in kitchen, family room, and near laundry area. Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils will be stored in a locked over head cabinet in the kitchen. Smoke Detectors/Carbon Monoxide(s): There are inter-connected combined smoke detectors and carbon monoxide; located throughout and all are operational. Appliances: Stove burners (gas), oven, microwave, coffee maker, blender, fryer and washer/dryer are in working condition. There is one (1) refrigerator in the home. Toxins: Cleaning supplies and toxins will be stored locked in a separate cabinet located under the kitchen sink only accessible to staff. Water Temperature: Hot water was tested in bathroom #1; temperature was 117.5 degrees F and within the normal limits (105-120F degrees). Medication, First-Aid Kit & Book: Designated centrally stored

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2021
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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME: LILLY'S OPEN ARMS IV
FACILITY NUMBER: 198320189
VISIT DATE: 08/18/2021
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medication will be locked in over head kitchen cabinet. First Aid Kit and Manual available with sufficient bandages, one (1) tweezer, thermometer, scissors. First Aid Book was also available.

Clients & Staff Files: Designated area for files will be stored in a locked cabinet located in family room,. Applicant will handle cash resources of clients and keep clients cash resources under lock in the facility. Pools/Jacuzzi & Pets: No bodies of water and no pets on these premises. Fire Clearance: Fire clearance was approved on 5/11/21 does advise of any delayed egress features and/or any locked perimeters.


LPA went over Infection control practices and requested applicant submit mitigation plan to LPA via email. LPA went over staff requirements such as fit- testing for respirators, surveillance testing, CDSS PINS shall be made available to staff and residents. LPA reminded applicant the following items shall be posted always: Personal rights, Emergency Disaster Plan/ Emergency numbers, Complaint Procedures, and facility sketch show emergency exits.

Component III Orientation: component was waived due to applicant having licensed facilities of the same category, ARF, by community care licensing division.


During the pre-licensing inspection zero (0) items were observed that didn’t comply with applicable laws and regulations.

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPAs will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021
LIC809 (FAS) - (06/04)
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