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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340311442
Report Date: 10/19/2023
Date Signed: 10/19/2023 04:41:12 PM


Document Has Been Signed on 10/19/2023 04:41 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
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: 4DATE:
10/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Renee AtesTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Avelina Martinez and Scott Brooks made an unannounced visit to this facility to conduct an annual inspection on 10/19/2023 at 2:25 PM. LPA Martinez met with Renee Ates and stated the purpose of today’s visit. LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator holds current certificate and expires in September of 2024. The facility is licensed for 6 non-ambulatory clients. There are currently 4 clients who reside at this facility. The facility has a hospice waiver for 1.

LPA Martinez toured the facility with on 10/19/2023 at 2:25 PM.

LPA Martinez reviewed two employee files and two client files, and the files were maintained. LPA Martinez reviewed one medication administration record, and the record was maintained. First Aid Kit was complete. The fire extinguishers, smoke detectors, and carbon detectors were in good repair. Facility has cameras mounted in the common areas. The cameras are not in working order, however, facility sketch should be updated to reflect mounted cameras. LPA Martinez requested a copy of surety bond and liability insurance The facility has infection control plan and emergency disaster plan. All requested document should be emailed to LPA Martinez by October 26 2023 by 5 PM. LPA observed the facility to have an adequate food supply. The following items were not in good repair: Window screens, sliding glass door screens, exterior fence, wheelchair ramp, emergency exit gate/door, freezer had frost bite build up. The items should be repaired by November, 09, 2023. A Plan of correction visit will be conducted to inspect repairs. The facility water temperature measured at 105 degrees and facility temperature measured at 78 degrees. As a result, of this annual visit, the facility was cited for fire clearance and Maintenance and Operation. Citations can be found on the 809-D page. An exit interview was conducted, and a copy of this 809 report, 809-D Page, and appeals rights were provided to the facility.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023
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


Document Has Been Signed on 10/19/2023 04:41 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: LILLIE CARE HOME
FACILITY NUMBER: 340311442

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/09/2023
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by
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The Administrator agrees to repair all items that are not in good repair by 11/09/2023. The POC will be cleared by POC visit.
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Based on observation and inspection, LPA Martinez found the following items not to be in good repair: Facility window screens, exterior emergency door ramp, exterior fence boards broken and nails exposed, freezer has frost bite. This posed a potential health and safety risk to clients in care.
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Type B
11/09/2023
Section Cited
CCR87203

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87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidence by:
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The Administrator agrees to repair Emergency/ fire gate/door 11/09/2023. The POC will be cleared by POC visit.
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Based on observation and inspection the exterior emergency/fire gate was not in good repair. This posed a potential health and safety risk to client.
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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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2