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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 340311442
Report Date: 11/02/2023
Date Signed: 11/02/2023 02:59:24 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/26/2023 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20231026091124
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: 3DATE:
11/02/2023
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Darlene BoydTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Staff spoke inappropriately towards resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tung Truong made an unannounced visit to the facility to commence a complaint investigation for the above allegation. LPA met with facility staff Darlene Boyd and explained the purpose of the visit.

Throughout the course of the investigation, LPA conducted interviews and reviewed records. Based on records reviewed and interviews conducted, staff (S1) spoke to client (C1) inappropriately on 10/23/23. According to a voicemail, S1 can be heard talking to C1 in a degrading manner. S1 told C1 that she is lazy, and that other care home would not put up with her behavior.

As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations.

Exit interview was conducted, a copy of the report, LIC 9099-D and appeal rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20231026091124
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/09/2023
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement is not met as evidenced by:
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All staff and administrator shall take In-Service training on verbal abuse, and residents personal rights. Administrator shall send proof of training to LPA by POC due date.
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Based on interviews and records review, the Licensee did not ensure residents were accorded dignity by Staff (S1). S1 spoke to C1 inappropriately on 10/23/23. This poses a potential health and safety risk to residents 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: 11/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2