198603571-7-2-2024-28-AS-MGFS-D6SSC2-20240702134450

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603571
Report Date: 07/02/2024
Date Signed: 07/02/2024 01:45:08 PM

Document Has Been Signed on 07/02/2024 01:45 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:	07/02/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:46 AM
MET WITH:	Artemio de la Pena - Staff		TIME COMPLETED:	02:00 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) Mary Flores and Michael Moriel conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Artemio de la Pena and explained the reason for the visit.

The facility is licensed to serve 4 non-ambulatory residents over the age of 60, of which 2 may be bedridden in room 3 and 4. Facility has a hospice waiver for two. The facility is a single-story home in a residential neighborhood and consist of a living room, dining area, kitchen, laundry area, 4 resident bedrooms, 2 resident bathroom, 2 Staff Rooms, 1 Staff bathroom, detached garage, front yard, and back patio.

LPA conducted a tour of the facility with Artemio de la Pena and observed the following:

Facility is in good repair indoor and outdoor. Living room has a covered fireplace. Dining room/living room have sufficient seating area. Kitchen was observed clean, sharps and cleaning solutions were observed locked. Sufficient food was observed for at least 2 days of perishables and 7 days of non-perishables. Each client room was observed with sufficient lighting, the required furniture and bedding supplies. Room #4 was observed with a hole in the front of the door of the size of a tennis ball. Bathrooms were observed clean and in good repair. Water temperature was tested between 101.1 and 102.1 degrees F., which is not within the required 105-120 degrees F. Facility has linens and grooming supplies for residents. Smoke/Carbon monoxide detectors were tested and are in working condition. Back patio was observed and few of the floor planks are chipping down, fence is being held by a wood plank per staff the tree is pushing the fence in, exit passage way to the garage was observed with plants overgrown. No large bodies of water were observed.
LPA reviewed medication and files for 4 residents and 4 staff files. Staff were missing 20 hours of training. Infection control plan was last reviewed on 6/30/22. Emergency Disaster plan was last reviewed on 7/8/22. Las fire drill was conducted on 5/28/24. Administrator certificate was observed for Anthony Shinn #6005240740 exp. date: 9/21/25.

Deficiencies were noted on LIC 809D per Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D, and appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

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 6

Document Has Been Signed on 07/02/2024 01:45 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: 07/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. 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 in room #4's door has a hole, back patio floor planks need to be replace, and back patio fence needs to be properly secured which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/16/2024
	Plan of Correction
1 2 3 4	Administrator will repair hole in the door, replace the patio floor planks, and properly secure the fence and submit pictures of the repairs to the department by POC due date 7/16/24.

Type B

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). 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 in water temperature was tested at 101.1 degrees F., in bathroom #1 and at 102.1 degrees F., in bathroom #2 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/16/2024
	Plan of Correction
1 2 3 4	Administrator will adjust the water temperature and maintain a daily log from 7/3/24 -7/15/24 to record water temperature and will submit a copy of the log to the department by POC due date 7/16/24.

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: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

LIC809 (FAS) - (06/04)

Page: 2 of 6

Document Has Been Signed on 07/02/2024 01:45 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: 07/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 staff did not have 20 hours of annual training which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/16/2024
	Plan of Correction
1 2 3 4	Administrator will provide 10 hours of training by 7/16/24 and will schedule additional10 hours of training by 7/30/24. Administrator will provide a copy of the fist 10 hours cocluded and proof of the 10 hours schedule by POC due date 7/16/24.

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: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

LIC809 (FAS) - (06/04)

Page: 3 of 6