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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601552
Report Date: 08/06/2024
Date Signed: 08/07/2024 11:30:44 AM


Document Has Been Signed on 08/07/2024 11:30 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:RODELIO AQUINOFACILITY TYPE:
740
ADDRESS:11419 WESTONHILL DRIVETELEPHONE:
(858) 271-6849
CITY:SAN DIEGOSTATE: CAZIP CODE:
92126
CAPACITY:6CENSUS: 4DATE:
08/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Administrator, Rodelio AquinoTIME COMPLETED:
01:35 PM
NARRATIVE
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Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management - Incident visit. LPA was greeted and met with Administrator, Rodelio Aquino.

On 06/23/24, the facility self reported an incident involving Resident #1 (R1). The incident occurred on 06/08/24, indicating R1 had a pressure injury and the administrator cleaned the area and applied barrier cream. The administrator was not aware of the stage of the pressure injury but stated it was reddened but not open. The report also stated the administrator prepared R1's belongings and R1 was transported back to their private home on 06/08/24 by the resident's choice. R1 was receiving hospice services. Title 22 Regulations require incidents to be reported within seven days of occurrence. However, the incident was reported wihin fifteen days. A review of records indicated, the facility did not have required hospice documentation for R1. In addition, the facility did not have hospice documentation for Resident #2 (R2). The administrator explained R1 no longer resides at the facility and the responsible party took the records and he did not retain copies. The administrator was advised records shall be maintained for three years. The administrator stated he will obtain hospice records for R2 and place them in the resident's file.

Deficiencies were issued and listed on the attached LIC 809D. A civil penalty was assessed for a repeat violation within a 12 month period. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Administrator, Rodelio Aquino 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: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024
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 08/07/2024 11:30 AM - 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: LILY OF THE VALLEY II
FACILITY NUMBER: 374601552

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/03/2024
Section Cited
CCR
87211(a)(1)

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Reporting Requirements. A written report shall be submitted...within seven days of the occurrence...(A) through (D) below. This report shall include... date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
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Administrator stated it was an oversight. Administrator agreed to attend training on reporting requirements and submit proof by POC due date.
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This requirement is not met as evidenced by: Based on record review and interviews, the licensee did not ensure an incident report was completed for 1 out of 4 residents [R1], which poses a potential health and safety risk to residents in care.
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A civil penalty was assessed for a repeat violation wthin a 12 month period.
Type B
09/03/2024
Section Cited
CCR87506(d)

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Resident Records. All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. This requirement is not met as evidenced by:
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Administrator stated he will attend training on resident records and provide proof of training by POC due date.
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Based on record review and interviews, the licensee did not ensure an incident report was completed for 2 out of 4 residents [R1-R2], which 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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024
LIC809 (FAS) - (06/04)
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