198603571-8-7-2023-28-AS-THEA-CUGRE7-20230807125703

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603571
Report Date: 08/07/2023
Date Signed: 08/07/2023 12:57:09 PM

Document Has Been Signed on 08/07/2023 12:57 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
GREATER LA AC/SC, 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: 4	DATE:	08/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Maria Shinn - Administrator		TIME COMPLETED:	01:10 PM

NARRATIVE

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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Art DeLaPena (Caregiver) and then Maria Shinn (Administrator) who later assisted with the visit. The facility is licensed to serve 4 Non-Ambulatory Residents with Hospice Waiver for 2.

The facility is located in a residential area in Los Angeles, Ca. A tour of the single-story facility includes: living room, dining area, kitchen, laundry area, 4 client bedrooms, 1 client restroom, 2 Staff Rooms, 2 1/2 Staff Restrooms, detached garage, front yard, and back patio.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents’ medications. Staff are still cleaning and disinfecting throughout the day. There is sufficient PPE supplies and an Infection Control Plan.

Operational Requirements: There are currently 4 ambulatory residents at the facility.
Physical Plant & Environment Safety: There are 4 client bedrooms, 1 client restroom, 2 Staff Rooms, 2 1/2 Staff Restrooms, living room, dining area, kitchen, laundry area, detached garage, front yard, and back patio. Bathrooms are clean and operational. LPA observed client restroom and sink in restroom is inoperable. Clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The back patio is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested throughout the facility and is within the required range of 105-120 degrees. All storage areas for cleaning solutions, toxins, knives, and hazardous items are stored in a secured, locked area and inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguisher was observed and is fully charged.
(Continued on 809-C)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LILY CREST MANOR, INC	FACILITY NUMBER: 198603571
	VISIT DATE: 08/07/2023

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Staffing: There appears to be sufficient staffing at all times in the facility. The administrator certificate for Maria Shinn expires 8/6/2024.
Personnel Records-Training: Staff has criminal record clearance and files are kept in a locked cabinet within the facility. Staff have current CPR/first aid training and sufficient on-going training.
Resident Rights-Information: Facility provides telephone and internet service for residents in care.
Resident Records-Incident Reports: Resident files are kept in a locked cabinet within the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.
Planned Activities: There are scheduled activities for the residents in care and there is sufficient space for indoor and outdoor activities available.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Staff designated to administer medication has the proper annual training on file. Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers. During the visit today, LPA reviewed all 4 residents' medication no issues were observed.
Incidental Medical & Dental: All medications for residents are kept locked and inaccessible to other residents.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites.
Residents with Special Needs: The facility currently does not have residents with any special needs such as dementia and hospice.

During todays visit LPA interviewed 2 Staff and 2 Clients.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on 809D.

Exit interview held and a copy of the report was provided to Administrator Maria Shinn.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 08/07/2023 12:57 PM - 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LILY CREST MANOR, INC	FACILITY NUMBER: 198603571
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(6)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as sink in client restroom was observed to be non-operable (clogged), which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/21/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator to call handy man and have repairs done within the next 7 business days. A copy of the invoice and photo of repairs will be sent via email to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023

LIC809 (FAS) - (06/04)

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