<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603155
Report Date: 11/15/2021
Date Signed: 11/15/2021 05:07:57 PM

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:LILAC CHATEAU 1FACILITY NUMBER:
374603155
ADMINISTRATOR:WITHERS, KIMBERLYFACILITY TYPE:
740
ADDRESS:9718 EUCALYPTUS COURTTELEPHONE:
(619) 312-1494
CITY:SANTEESTATE: CAZIP CODE:
92071
CAPACITY:6CENSUS: 4DATE:
11/15/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:39 PM
MET WITH:Licensee, Kimberly WithersTIME COMPLETED:
01:32 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Kristina Ryan conducted a case management visit to cite for a deficiency observed while completing a records review for a complaint. LPA met with Licensee, Kimberly Withers, and discussed the purpose of the visit.

While reviewing records for a complaint, LPA found that Resident 1 (R1) was admitted and retained with a diagnosis and symptoms of a contagious infection. Interviews with facility staff revealed that the staff were aware that (R1) had a history of this infection, and symptoms of the infection began the same day that R1 moved in.

A deficiency is being cited pursuant to Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on an LIC 809-D.

An exit interview was conducted, and this report was discussed with the licensee. A copy of the report, LIC 809-D, and Licensee/Appeal Rights (LIC 9058 01/16) will be emailed to the licensee following the visit. Acknowledgement of receipt of the documents is requested upon receipt
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina RyanTELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021
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
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: LILAC CHATEAU 1
FACILITY NUMBER: 374603155
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/09/2021
Section Cited

1
2
3
4
5
6
7
87615 Prohibited Health Conditions (a) (4) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: Staphylococcus aureus ("staph") infection or other serious infection. This requirement was not met as evidenced by;
8
9
10
11
12
13
14
Based on record review and interviews, the licensee did not ensure, that one out of four residents, did not have a prohibited health condition. This posed a potential Health risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina RyanTELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2