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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604295
Report Date: 05/23/2024
Date Signed: 05/23/2024 03:02:02 PM


Document Has Been Signed on 05/23/2024 03:02 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:RESIDENCE CARE INC DBA LILLY'S VILLA II, THEFACILITY NUMBER:
374604295
ADMINISTRATOR:WINBLAD, MAGDARLINEFACILITY TYPE:
740
ADDRESS:5996 SAGEBRUSH RDTELEPHONE:
(619) 757-3918
CITY:LA JOLLASTATE: CAZIP CODE:
92037
CAPACITY:6CENSUS: 6DATE:
05/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Administrator Magdarline WinbladTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required Annual Inspection. The LPA introduced himself and disclosed the purpose of the visit to Administrator Magdarline Winblad. The facility was licensed for a capacity of six (6) non-ambulatory residents, of which one (1) may be bedridden. A hospice waiver for four (4) residents was also approved by the Department.


The LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Faucets and showers used delivered water within the normal temperature range. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to residents. Medications were labeled, and stored in a locked area.



No pools, nor bodies of water were observed on the premises. Per staff, no firearms, nor ammunition were kept at the facility. A carbon monoxide detector, facility telephone. and multiple fire extinguisher(s) were in working order. Required licensing postings were observed in a visible area of the facility.

The LPA interviewed staff and reviewed multiple staff and client records. The files which LPA reviewed contained required documents. No deficiencies were observed or cited during today's annual inspection.

An exit interview was conducted with Administrator Winblad, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058), were provided.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024
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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