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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340311442
Report Date: 12/07/2022
Date Signed: 12/07/2022 02:42:34 PM


Document Has Been Signed on 12/07/2022 02:42 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:LILLIE CARE HOMEFACILITY NUMBER:
340311442
ADMINISTRATOR:ARLYNN WILLIAMSFACILITY TYPE:
740
ADDRESS:6831 GOLF VIEW DRIVETELEPHONE:
(916) 391-2302
CITY:SACRAMENTOSTATE: CAZIP CODE:
95822
CAPACITY:6CENSUS: 4DATE:
12/07/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Renee AtesTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced on 12/7/2022 to conduct a case management visit. Upon LPAs arrival, Caregiver Shaquita Haywood was present and contacted facility staff Renee Ates who arrived a bit later. LPA met with Renee Ates and explained the purpose of the visit. There are currently 4 residents who reside at this facility.

The purpose of the visit today is in response to substantial inadequacies identified by Alta California Regional Center during an annual Title 17 Monitoring Review on 11/21/2022. It was learned that the facility was placed on sanction on 12/6/2022 due to the following deficiencies:
- Failure to provide consumer services as specified in the consumer’s IPP.
- Failure to comply with the requirements for administrator and staff qualifications and/or administrator and staff training.
- Failure to ensure that a direct care staff completes the competency based training and testing required.

As a result, the following deficiencies were cited from the California Code of Regulations, Title 22, and California Health and Safety Code. The deficiencies can be found on the 809-D page.

Exit interview was conducted, a copy of this report, 809-D, and appeal rights were provided.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2022
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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Document Has Been Signed on 12/07/2022 02:42 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: LILLIE CARE HOME
FACILITY NUMBER: 340311442

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/15/2022
Section Cited

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Administrator - Qualifications and Duties. The administrator shall perform the following duties…(4) Recruit, employ and train qualified staff… (5) Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs. This requirement is not met as evidenced by:
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Based on records review, the licensee did not ensure client's medication reason of use is filed and direct care staff completes the competency-based training and testing as required. This poses a potential health and safety risk to clients in care.
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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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2022
LIC809 (FAS) - (06/04)
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