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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340311442
Report Date: 11/15/2023
Date Signed: 11/15/2023 08:53:22 AM


Document Has Been Signed on 11/15/2023 08:53 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
11/15/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Shaquta HaywoodTIME COMPLETED:
09:10 AM
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Licensing Program Analysts (LPAs) Avelina Martinez and Pang Lee arrived at facility unannounced to conduct a plan of correction (POC) visit. LPAs met with Shaquta Haywood and explained the purpose of the visit on 11/15/2023.

The purpose of this visit is to follow-up on citations issued on 10/19/2023 during an annual inspection visit.

During the 10/19/2023 visit, LPA Martinez observe the following items to be not in good repair: exterior emergency gate, window screens, sliding glass door screen, fence boards, and freezer door. The deficiencies were cited on the day of 10/19/2023 visit. Moreover, LPA Martinez requested the following POC’s to be corrected by: 11/09/2023.

Based upon this inspection, LPAs Martinez and Lee observed the following POC’s to be corrected. The Deficiencies cited have been cleared. Licensee complied with the terms of the plan of correction and corrected the deficiencies by the plan of correction due date.



An exit was conducted, and a copy this report was provided to the facility.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023
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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