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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603155
Report Date: 11/29/2023
Date Signed: 11/29/2023 08:01:21 PM


Document Has Been Signed on 11/29/2023 08:01 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
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: 6DATE:
11/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Licensee Kimberly WithersTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Debbie Correia made an unannounced visit to the facility to conduct the required annual licensing inspection. LPA was met by Licensee Withers, identified herself, was granted entry into the facility, and stated the purpose of today’s visit, to ensure that the facility is in compliance with the California Code of Regulations, Title 22, Division 6. There were 6 residents and 5 staff present during today's visit. LPA Correia conducted a general overall inspection. The facility is licensed to serve 6 residents, age 60 and over, six (6) of whom can be non-ambulatory, and two (2) bedridden.

The facility temperature was 74 degrees Fahrenheit at the time of the visit. The resident bathroom's hot water temperature measured 109.5 degrees Fahrenheit. Disinfectants, cleaning solutions, and poisons were inaccessible to residents. All resident rooms were equipped with the required furnishings. Resident bathrooms were observed to be sanitary and equipped with the required supplies. Showers had grab bars and nonskid flooring. Lighting was maintained in hallways and passages to client bathrooms. Facility staff provided each resident with clean linen in good repair, and sufficient hygiene products for personal use. LPA Correia observed smoke alarms, and carbon monoxide detectors throughout the facility that were in operable condition. Per Licensee Withers there are no weapons and/or ammunition housed in the facility, nor does the facility have any bodies of water on the premises.

SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2023
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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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
VISIT DATE: 11/29/2023
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The facility is stocked with a 2 day supply of perishable and 7 day supply of nonperishable food items. The food was observed properly stored. Medications are stored in a locked cabinet and administered according to the label instructions. The facility's last disaster drill was conducted on November 9, 2023.

Per staff records reviewed, individuals subject to a criminal record review obtained clearance and/or an exemption; staff responsible for direct care and supervision have current First Aid and CPR training. Licensee Withers Administrator Certificate is current until April 10, 2024.



Based on today's visit, there were no deficiencies observed at this time in the areas evaluated. An exit interview was conducted with Licensee Withers and will be provided with a copy of this report and licensee/appeal rights (LIC 9058 01/16), and their signature on this form acknowledges receipt of these documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2