374603155-11-20-2024-08-AS-DCOA-DB7MRK-20241120085029

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603155
Report Date: 11/19/2024
Date Signed: 11/20/2024 08:51:34 AM

Document Has Been Signed on 11/20/2024 08:51 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	LILAC CHATEAU 1		FACILITY NUMBER:	374603155
ADMINISTRATOR/ DIRECTOR:	WITHERS, KIMBERLY		FACILITY TYPE:	740
ADDRESS:	9718 EUCALYPTUS COURT		TELEPHONE:	(619) 312-1494
CITY:	SANTEE	STATE: CA	ZIP CODE:	92071
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	11/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:30 AM
MET WITH:	Licensee Kimberly Withers		TIME VISIT/ INSPECTION COMPLETED:	03:45 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.

The facility is licensed to serve 6 residents, age 60 and over, six of whom can be non-ambulatory, and two bedridden, and approval for two residents receiving hospice services. During today's visit there was 6 residents and 5 staff present. LPA conducted a general overall inspection.

The facility temperature was 74 degrees Fahrenheit at the time of the visit. The resident bathroom's hot water temperature measured 114.3 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, including grab bars and nonskid flooring in the showers. LPA observed smoke alarms, and carbon monoxide detectors throughout the facility that were in operable condition. Fire extinguishers were present and current on inspections. The facility’s outdoor area was free from obstructions and had a shaded area and sufficient space for activities and visitations. 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.

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 were stored in a locked cabinet. The facility's last disaster drill was conducted on 8/13/2024. The facility’s liability insurance is current until 10/1/2025. LPA observed a sufficient amount of PPE supplies and disinfectants that were inaccessible to residents.

Jennifer Lott	TELEPHONE: (619) 346-3976
Debbie Correia	TELEPHONE: (619) 407-0894
	DATE: 10/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LILAC CHATEAU 1	FACILITY NUMBER: 374603155
	VISIT DATE: 11/19/2024

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Staff records reviewed, included criminal clearance and staff responsible for direct care and supervision have required training and current First Aid and CPR certification. Licensee Withers Administrator Certificate is current. All resident records were present and up to date.

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: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

LIC809 (FAS) - (06/04)

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