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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604980
Report Date: 07/23/2026
Date Signed: 07/23/2026 04:27:52 PM

Document Has Been Signed on 07/23/2026 04:27 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:LILOS TENDER SENIOR CARE INC.FACILITY NUMBER:
374604980
ADMINISTRATOR/
DIRECTOR:		MOLINA, STEPHANIEFACILITY TYPE:
740
ADDRESS:7949 EASTRIDGE RDTELEPHONE:
(818) 284-2502
CITY:LA MESASTATE: CAZIP CODE:
91941
CAPACITY: 6CENSUS: 6DATE:
07/23/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Administrator, Stephanie MolinaTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced case management visit while conducting a Health & Safety visit to open a complaint investigation. The LPA introduced herself, and discussed the purpose of the visit with Caregiver, Erik Mendoza. It was noted that Caregiver Mendoza had a current criminal record clearance; however, he was not associated with this facility and has been working at the facility since October 2024. During the visit, LPA discussed the purpose for the visit with Licensee, Anna Petrosyan.

Record review disclosed an additional staff member currently working at the facility that was not associated with the facility. In addition, during review of facility sketch and fire clearance it was disclosed that licensee exceeded capacity for non-ambulatory status. The facility is currently licensed for five (5) non-ambulatory and one (1) ambulatory status. During today's visit, a total of six (6) non-ambulatory residents were in care.

Deficiencies were cited during today's visit. Civil penalties in the amount of $1,500 were assessed for violations and are documented on the attached LIC 421. A plan of correction was developed in coordination with Licensee, Anna Petrosyan.

An exit interview was conducted with Administrator Stephanie Molina. She was provided copies of this report, LIC 809D Deficiencies, LIC 421s Civil Penalty, and Licensee/Appeal Rights (LIC 9058, 03/22).
Sabel Martinez
Marisela Garcia-Centeno
DATE: 07/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/23/2026 04:27 PM - It Cannot Be Edited


Created By: Marisela Garcia-Centeno On 07/23/2026 at 12:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LILOS TENDER SENIOR CARE INC.
FACILITY NUMBER: 374604980

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/23/2026
Section Cited
CCR
87355(e)

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887355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility. This requirement is not met as evidenced by:

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Licensee completed the association for one of the staff members during the visit on 7/23/2026 which eliminated immediate safety risk to residents in care. Licensee agreed to associate the 2nd caregiver prior to returning to work. Licensee agreed to submit documentation to CCL by POC deadline.
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Based on record review, the licensee did not comply with the section cited above in 2 out of 7 staff were not associated to the facility roster, which poses an immediate safety risk to 6 out of 6 persons in care.
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Type A
07/24/2026
Section Cited
CCR87202(a)(1)

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87202(a)(1) Fire Clearance
All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department …(1) Nonambulatory persons. This requirement is not met as evidenced by:

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Licensee agreed to submit application to CCL to request an increase in non-ambulatory status from 5 to 6. A new fire clearance will be requested. Licensee agreed to submit the application by POC deadline of 7/24/2026
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Based on observation and staff interviews it was disclosed that licensee exceeded non-ambulatory capacy.Faciltity is licensed for 5 non-ambulatory and currently 6 residents in care are non-ambulatory. R1 was in an ambulatory room and they were condidered non-ambulatory.
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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.
Sabel Martinez
NAME OF LICENSING PROGRAM MANAGER:
Marisela Garcia-Centeno
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2026


LIC809 (FAS) - (06/04)
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