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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
340311442
Report Date:
01/23/2025
Date Signed:
01/23/2025 01:42:28 PM
Document Has Been Signed on
01/23/2025 01:42 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
SACRAMENTO SOUTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
LILLIE CARE HOME
FACILITY NUMBER:
340311442
ADMINISTRATOR/
DIRECTOR:
ARLYNN WILLIAMS
FACILITY TYPE:
740
ADDRESS:
6831 GOLF VIEW DRIVE
TELEPHONE:
(916) 391-2302
CITY:
SACRAMENTO
STATE:
CA
ZIP CODE:
95822
CAPACITY:
6
TOTAL ENROLLED CHILDREN:
0
CENSUS:
3
DATE:
01/23/2025
TYPE OF VISIT:
POC
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:
Shaquita Haywood
TIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On 1/23/25 Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced plan of correction (POC) to ensure the Plan of correction has been completed from previous citation.
LPA observed the facility is still in process of completing POCs and have submitted documentation to address FAR issued by Alta Regional Center.
LPA did observe that previously observed paint cans and items stored under a table on the patio are still present after LPA Gould issued an advisory note (technical violation) for the items not stored inaccessible to clients in care.
LPA reminded the newly appointed administrator to complete all POCs by the POC due date.
Per California Code of regulations, Title 22 The following deficiency is cited during today's inspection.
Exit interview conducted and a copy of this report and appeal rights were left at the facility.
Czarrina A Camilon-Lee
TELEPHONE:
(916) 214-5136
Kevin Gould
TELEPHONE:
(619) 672-5924
DATE:
01/23/2025
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/23/2025
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
01/23/2025 01:42 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
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:
01/23/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Storage Space: Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to
Deficient Practice Statement
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POC Due Date:
01/31/2025
Plan of Correction
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4
Licensee agrees to dispose of or store items inaccessible to residents by the POC due date: 1/31/25.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
TELEPHONE:
(916) 214-5136
Kevin Gould
TELEPHONE:
(619) 672-5924
DATE:
01/23/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/23/2025
LIC809
(FAS) - (06/04)
Page:
2
of
2