198603571-7-20-2022-28-AS-DSIS-CGHQQY-20220720122305

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603571
Report Date: 07/20/2022
Date Signed: 07/20/2022 12:23:16 PM

Document Has Been Signed on 07/20/2022 12:23 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:	LILY CREST MANOR, INC		FACILITY NUMBER:	198603571
ADMINISTRATOR:	SHINN, ANTHONY A		FACILITY TYPE:	740
ADDRESS:	900 N. ALEXANDRIA AVENUE		TELEPHONE:	(323) 661-1784
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90029
CAPACITY:	4	CENSUS: 3	DATE:	07/20/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Maria Shinn, Anthony Shinn, Artemio De La Pena		TIME COMPLETED:	12:37 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) David Sicairos conducted an announced Pre-Licensing facility Evaluation visit. LPA met with Licensees Maria Shinn and Anthony Shinnm and DSP Artemio De La Pena who assisted with the visit. The home is located in a residential neighborhood within the city of Los Angeles and is a one story building which consists of (4) resident bedrooms, (1) staff bedroom, (3) bathrooms, supply room, living room, dining room, kitchen, and detached garage. The following was inspected during the evaluation with Mr. De La Pena and determined to be compliant with Title 22 Regulations. A locked storage area for central storage of medications was observed in the dining room. Cleaning supplies were separate from where food supplies are stored. The walls, ceilings, floors, window screens and areas around the facility were clean and in good repair. A locked storage area in the hallway for cleaning solutions and disinfectants was observed. A fire extinguisher was located in the kitchen of the home. Carbon monoxide detectors was observed in the hallway of the home. Smoke detectors were observed throughout the facility and were tested and operable. Doors, exits, hallways, and passageways were clear and free of obstruction. The front and back yards were observed to be clean and free of debris. No pools or bodies of water were observed in or around the home. Grab bars and non-skid mats were observed in the bathrooms. There are no firearms present at the facility. An operating telephone was observed on the premises, which is easily accessible and available for resident use. The first-aid kit was observed and is kept in the medication cabinet which included all required supplies. The refrigerator was observed to be at 45 degrees Fahrenheit and the freezer at 0 degrees Fahrenheit. Food storage and preparation areas, which includes pantries, cupboards, drawers and counters were observed to be clean and appropriate for food preparation. Appliances such as a microwave, refrigerator and stove were observed to be clean and operating properly. Food utensils, dishes, and glasses were clean and sufficient for the number of clients to be served. (CONTINUED ON 809C)

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

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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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: LILY CREST MANOR, INC	FACILITY NUMBER: 198603571
	VISIT DATE: 07/20/2022

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Hot water temperature was tested in bathroom #1 and read at 110F which is within the required 105F - 120F. The outdoor patio in the backyard was observed to have well shaded area and was furnished for outdoor use. Bedrooms have a mattress, pad, bedsprings, and a pillow which were clean. Each bed had a clean fitted sheet, pillowcase, blanket and bedspread. It was observed that resident bedrooms have adequate dresser and closet space for clothing and other belongings. Supplies for resident personal hygiene was observed to be made available on site.

The Component III Orientation was also conducted during today's visit. No outstanding or pending items were observed by LPA requiring additional follow up visits. LPA will notify the assigned Centralized Applications Bureau (CAB) Analyst of the completed Pre-Licensing facility evaluation visit conducted.

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

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

LIC809 (FAS) - (06/04)

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