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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603095
Report Date: 07/13/2026
Date Signed: 07/13/2026 04:05:33 PM

Document Has Been Signed on 07/13/2026 04:05 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:LILAC CARE RESIDENTIAL HOME LLCFACILITY NUMBER:
198603095
ADMINISTRATOR/
DIRECTOR:		CALINGASAN, GILFACILITY TYPE:
735
ADDRESS:16502 E QUEENSIDE DRTELEPHONE:
(213) 388-2229
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY: 4CENSUS: 2DATE:
07/13/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Lety Cirilo TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analysts (LPA) Nune Margaryan conducted an unannounced annual visit using the Care Tool. LPA met with staff Lety Cirilo and explained the reason for the visit. Administrator Gil Calingasan arrived shortly after and assist with the visit. The physical plant was inspected along with medications, food supply, and client and staff records. The facility is licensed to serve developmentally disable clients between the ages 18 to 59. There are currently 2 clients residing at the home and receive services from San Gabriel / Pomona Regional Center and Lanterman Regional Center. At the time of visit both clients were at the Day program.

The facility is a single-story home located in a residential area. LPA toured the home and inspected dinning room, living room /activity room, kitchen, three (3) client bedrooms, two (2) bathrooms and detached garage. The front and backyard are well maintained and there are no pools or large bodies of water. Passageways and exits are free of obstruction. There is a shaded seating area for the clients located in the backyard. Laundry was observed at the end of the kitchen. laundry detergent were locked in the cabinet in the laundry area inaccessible to clients. The kitchen was inspected. There is sufficient perishable and non-perishable food. Sharps are locked in the kitchen drawer and inaccessible to clients. Cleaning supplies observed locked under sink cabinet. LPA observed that 3 of 4 gas burners were not operational. Client bedrooms were checked. Client bedrooms have the required furniture. Clients beds have the required linen, and the linen is in good condition. Extra linens, blankets, towels, and personal hygiene supplies were observed in the closet located in the hallway and in the locked cabinet located in laundry area. Bathrooms are clean and operational. The hot water temperature was tested and was measured within Title 22 Regulation guidelines.

Continue 809C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/13/2026 04:05 PM - It Cannot Be Edited


Created By: Nune Margaryan On 07/13/2026 at 02:42 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LILAC CARE RESIDENTIAL HOME LLC
FACILITY NUMBER: 198603095

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(21)
80076 Food Services
(a) In facilities providing meals to clients, the following shall apply:
(21) Equipment necessary for the storage, preparation and service of food shall be provided, and shall be well-maintained.



This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. During the facility tour LPA observed that 3 of 4 gas burners were not operational, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2026
Plan of Correction
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Licensee / Administrator will repair or replace the non-operetional burners and submit proof of repair, such as an invvoice, receipt or photograph showing the stove is fully operational by POC due date.
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.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Nune Margaryan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2026


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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LILAC CARE RESIDENTIAL HOME LLC
FACILITY NUMBER: 198603095
VISIT DATE: 07/13/2026
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Fire extinguishers were observed in the kitchen area and in the hallway are fully charged. Smoke Detectors and carbon monoxide detectors were operable. LPA observed the centrally stored medication cabinet to be locked in the Living / activity room and inaccessible to clients. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. LPA reviewed client's files and observed that all files are updated. LPA confirmed staff working have fingerprint clearances. LPA reviewed clients medications. Medications are documented properly and given as prescribed. Fire drill was conducted on 06/22/2026.

Observed deficiency noted on 809D

Exit interview was conducted with Administrator and a copy of this report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2026
LIC809 (FAS) - (06/04)
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