<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003930
Report Date: 05/08/2023
Date Signed: 05/08/2023 02:52:05 PM

Document Has Been Signed on 05/08/2023 02:52 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'S HOMEFACILITY NUMBER:
306003930
ADMINISTRATOR:MARILYN PAGUIOFACILITY TYPE:
735
ADDRESS:11408 177TH STREETTELEPHONE:
(562) 860-9642
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY: 4CENSUS: 3DATE:
05/08/2023
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Administrator Marilyn PaguioTIME COMPLETED:
03:10 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
On 5/08/23 at 8:40 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to Lily’s Home. Upon arrival LPA was greeted by Direct Support Professional (DSP) Emeripa Daco who contacted the Administrator, Marilyn Paguio, at 8:50 am. This home is licensed to serve (4) Developmentally Disabled Ambulatory Adults, (1) non-Ambulatory and (3) Ambulatory Adults ages 18 through 59. The is a level 4I home and the vendor is Harbor Regional Center. There were (2) clients in care during the time of this visit, the other (1) client were at the day program. The last emergency disaster/fire drill was conducted on 5/01/23. The Administrator Certificate expires on 7/5/2023 #6005366735. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (4) staff files, (3) client files, medications, and medication administration records for (3) clients and P&I.

This home contains 4 bedrooms,1 staff bedroom, 2 bathrooms, 2 living room, office, laundry room, kitchen, dining room and an attached garage. LPA toured the physical plant with the Staff Emeripa Daco. and observed all (4) client bedrooms, contained required furniture, lamps, dresser, chair, and closet space. The two bathrooms contain a working toilet, basin and water faucet, walk in shower with grab bar, shower chair, and bathmat. The temperature measured at 115.3*F-118.7*F. The smoke detectors were battery operated and individually tested and observed to be working properly. The carbon monoxide detector was located throughout the facility, tested, and functioning properly. There were (1) fire extinguisher located in the living room fully charged and up to date. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans with knives secured and locked underneath kitchen sink with cleaning agents and toxins. The pantry was well stocked with canned goods, pasta, cereals, and the food supply contained a sufficient supply with a two-day supply of perishables and a seven-day supply of non-perishables that met title 22 guidelines. Walls and floors, cabinets and counters were clean and sanitary throughout the home
(Report continued on LIC809C.)
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2023
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 2
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'S HOME
FACILITY NUMBER: 306003930
VISIT DATE: 05/08/2023
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
26
27
28
29
30
31
32
The outdoor grounds were toured and inspected, and the patio was well maintained with a shaded seating area accessible for client use. The garage contained storage supplies and seating area for staff.

Exit interview conducted with Staff Emeripa Daco, a copy of this report was provided, and Appeal rights given.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2