198603571-8-20-2026-28-AS-LDLN-DX5Q6J-20260820115338

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603571
Report Date: 08/20/2026
Date Signed: 08/20/2026 11:59:23 AM

Document Has Been Signed on 08/20/2026 11:59 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	LILY CREST MANOR, INC		FACILITY NUMBER:	198603571
ADMINISTRATOR/ DIRECTOR:	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:	08/20/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:30 AM
MET WITH:	DSP Jeremiah Quijano		TIME VISIT/ INSPECTION COMPLETED:	12:15 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	License Program Analysts (LPA) Luis De Leon conducted an unannounced annual required visit. LPA met with DSP Jeremiah Quijano who contacted administrator and informed administrator of today’s visit. Administrator Anthony Shinn joined visit sometime after. The purpose of today’s visit was explained. The facility is licensed to serve adults 60 years and over, of which two (2) may be bedridden. The licensee is approved for 2 hospice waivers. Residents are serviced by Frank D. Lanterman Regional Center. The LPA use the Compliance & Regulatory Enforcement Tool (CARE) during today’s inspection. The visit consisted as follows: FACILITY PHYSICAL PLANT The facility is in a residential area and is made up of four (4) resident bedrooms and two (2) staff bedroom, two (2) full bathrooms for resident use and one (1) staff bathroom, living room, dining room, laundry room, front and backyard, and a detached car garage. There were no body of water observed in the property. REVIEW OF FILES Resident record review consisted of Admission Agreements, Identification and Emergency Info, medical assessment, Consent Report, Individual Program Plan, Personal Rights, and Centrally Store Medication. LPA observed that the medical assessment for resident 3 (R3) was missing from resident’s file. R3 is a recent placed resident at the facility. A deficiency is noted on LIC-809D for missing medical assessment. Staff record review consisted of Personnel Report, Health Screening, Criminal Record Statements, Fingerprint Clearance, Training, First Aid and CPR. LPA review facility’s infection control plan, emergency and disaster plan, and liability insurance. (Report continues on page LIC-809C...)

Fernando Fierros
Luis DeLeon
	DATE: 08/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2026

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 08/20/2026 11:59 AM - It Cannot Be Edited

Created By: Luis DeLeon On 08/20/2026 at 11:24 AM

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: LILY CREST MANOR, INC	FACILITY NUMBER: 198603571
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/20/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in disinfectants, cleaning solutions and poisonous substances were observed in the backyard accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/21/2026
	Plan of Correction
1 2 3 4	Licensee shall remove all disinfectant and toxics and stored all items in a secured location inaccessible to residents in care by POC. Licensee removed all items during visit and place disinfectant and toxics in a locked storage room.

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.

	Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:

	Luis DeLeon
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/20/2026 11:59 AM - It Cannot Be Edited

Created By: Luis DeLeon On 08/20/2026 at 11:24 AM

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: LILY CREST MANOR, INC	FACILITY NUMBER: 198603571
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/20/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in one (1) out of four(4) residents medical assessment. R3 was recently placed at facility and R3 did not have a medical assessment in R3's facility file, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/04/2026
	Plan of Correction
1 2 3 4	Licensee shall obtain the medical assessment for R3 and shall submit a copy of R3's medical assessment to licensing by POC 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.

	Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:

	Luis DeLeon
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2026

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LILY CREST MANOR, INC	FACILITY NUMBER: 198603571
	VISIT DATE: 08/20/2026

NARRATIVE

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Observations during facility tour:

Bedrooms were furnished with a bedframe, dresser, lamps, and chairs. LPA observed that there was clean linen, bath towels, and personal hygiene with reasonable closet space available for residents.
Walls and floors are in good repair. Hallways were clean and free of obstructions.
Kitchen appliances were in working order and clean. There is sufficient two (2) days of perishables and seven (7) day supply of non-perishable food. Dining room has sufficient seating area.
Toilets, showers, and water faucets are found in compliance with Title 22 regulations for temperature and function. Restrooms were stocked and clean. The water temperature was tested and measured. It was found in compliance with Title 22 regulations between 105º and 120º F degrees.
Sharps are locked inside the kitchen and inaccessible to residents. Also, Disinfectants and toxics supplies were observed to be in the backyard accessible to residents in care. A deficiency is noted on LIC-809D.
Smoke detectors were observed in all bedrooms and carbon monoxide detectors were observed in living room around hallway area. One (1) fire extinguisher was observed and was fully charged with last inspection on 08/27/2025.
Last fire drill and earthquake drill were conducted on 05/09/2026.
Front yard has a shaded seating area for residents to enjoy.
The medications are centrally stored and locked in the staff room. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for all four (4) residents.
LPA conducted interviews with one staff. Residents were out in the community.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC-809D page. Exit interview was held and copies of reports LIC-809, LIC-809C, LIC 809D, and Appeal Rights were discussed and provided to Administrator Anthony Shinn.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Luis DeLeon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2026

LIC809 (FAS) - (06/04)

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