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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200183
Report Date: 12/28/2021
Date Signed: 12/28/2021 12:09:50 PM

Document Has Been Signed on 12/28/2021 12:09 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:LILY AVENUE HOMEFACILITY NUMBER:
435200183
ADMINISTRATOR:AMY HELLYERFACILITY TYPE:
735
ADDRESS:1105 LILY AVENUETELEPHONE:
(408) 341-0400
CITY:SUNNYVALESTATE: CAZIP CODE:
94085
CAPACITY: 6CENSUS: 3DATE:
12/28/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:AMY HELLYERTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Christine Dolores conducted an unannounced case management visit. This case management visit was regarding a death report received on 12/19/2021 involving resident (R1). LPA met with House Manager (HM) Nsawa Francisco, Administrator (ADM) Amy Hellyer, and Executive Director Mark Fleming.

LPA toured the facility inside and outside to include the living room, 4 resident rooms, 2 bathrooms, kitchen, dining room, laundry room, garage, and backyard. There are currently 3 residents at the facility. 2 residents were observed participating in a day program and 1 resident was watching a movie.

LPA spoke with HM and ADM in regards to the incident. HM and ADM confirmed R1's health condition and states R1's seizures happens about 1-4 times a week. Staff are to reposition R1 on the back when laying down for naps but can be repositioned on the belly based on R1's preference. ADM stated emergency procedures to include calling the Christian Science Practitioner first, then to contact the ADM, and the ADM will assess the situation further and confirm if 911 should be called.

LPA obtained R1’s daily chart and practitioner call/visit/care log for 07/2021, 08/2021, and 12/2021, 2020 needs and services plan, SARC Semi-annual report from 06/2021 - 08/2021, resident care plan, emergency contact information, and IPP. LPA requested ADM to send R1's 2021 appraisal needs and services plan, 09/2021 - 11/2021 daily chart and practitioner call/visit/care log and death certificate when obtained.

No deficiencies cited today per California Code of Regulations, Title 22.

This report was reviewed with Administrator Amy Hellyer and Executive Director Mark Fleming and a copy of this report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2021
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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