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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601552
Report Date: 01/24/2024
Date Signed: 01/25/2024 10:36:06 AM


Document Has Been Signed on 01/25/2024 10:36 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:LILY OF THE VALLEY IIFACILITY NUMBER:
374601552
ADMINISTRATOR:ELISOL PUNAYFACILITY TYPE:
740
ADDRESS:11419 WESTONHILL DRIVETELEPHONE:
(858) 271-6849
CITY:SAN DIEGOSTATE: CAZIP CODE:
92126
CAPACITY:6CENSUS: 5DATE:
01/24/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Staff, Khymberlie TalledoTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Plan of Correction visit. LPA was greeted and allowed entry into the facility by Staff, Khymberlie Talledo.

On 12/20/23, the facility was issued deficiencies due on 01/16/24. Staff, Rodelio Aquino requested an extension through 01/30/24, which was approved for the following deficiencies: Proof of liability insurance and remove all the unwanted items in the backyard and repair or replace all the torn window screens.

As of today, the following deficiencies have not been corrected: Hospice exception for Resident #1; and Incident Report for Resident #2.

There were also repeat violations for deficiencies: Hot water temperature and medications not locked.

Today, LPA observed the hot water temperature measured at 125 degrees F., Resident #3 had medications in their room on a tray table in front of them for easy access, and the refrigerated medications were not locked.

Based on observations, repeat violations and failure to correct were issued along with civil penalties.

An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Staff, Khymberlie Talledo whose signature below confirms receipt of these rights.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024
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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