<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200183
Report Date: 10/02/2024
Date Signed: 10/02/2024 02:22:43 PM

Document Has Been Signed on 10/02/2024 02:22 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:LILY AVENUE HOMEFACILITY NUMBER:
435200183
ADMINISTRATOR/
DIRECTOR:		AMY HELLYERFACILITY TYPE:
735
ADDRESS:1105 LILY AVENUETELEPHONE:
(408) 341-0400
CITY:SUNNYVALESTATE: CAZIP CODE:
94085
CAPACITY: 6CENSUS: 4DATE:
10/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Amy Helleyer and Jackie Leonard-DimmickTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On October 2, 2024, Licensing Program Analyst (LPA) Kiran Jain arrived at the facility at 12:20 PM to conduct the Annual 1-year required inspection. Upon arrival, LPA met with the Amy Helleyer, Administrator, and Jackie Leonard-Dimmick, caregiver, and explained the purpose of the visit.

At 12:28 PM, LPA began the tour of the physical plant in the presence of the Administrator. The facility sketch includes 4 resident bedrooms, 2 bathrooms, a living room, a kitchen with dining/family room, a laundry area, an office area, a garage, and 6 exit doors for access to the exterior area of the facility. The facility was observed to be clean, in good repair, and maintained at a comfortable temperature with adequate lighting. During the tour two staff members were seen present in the facility. The residents were away at the day programs. No accessible bodies of water or fire safety/tripping hazards were observed.

At 12:36 PM, LPA inspected residents’ rooms and observed them to be clean with sufficient furniture and operational light fixtures. Auditory alarm was observed working on the exit door of bedroom #3 for an Ambulatory resident. The bathrooms were observed to be clean and contained grab bars, trash cans, liquid soap, and paper towels. The bath area had a shower chair. The bathroom faucet hot water temperature was measured at 118.6°F.

At 12:48 PM, LPA inspected the kitchen and observed it to be clean. Toxins, cleaning supplies, and sharp objects were stored/locked properly and inaccessible to residents. The facility had an adequate stock of food items, including 7 days of non-perishables and 2 days of perishables, with no expired items were observed.

At 12:54 PM, LPA inspected the fire extinguishers, which were observed to be fully charged and last serviced on June, 2024. The smoke and carbon monoxide detectors were tested and observed to be operational.

At 12:57 PM, LPA inspected the laundry area and observed it to be clean and equipped with a washer and dryer. The hallway closet was observed to contain an additional linen supply.

At 1:02 PM, LPA inspected the garage and observed it to be clutter-free and clean. LPA observed 1 Freezer, 1 Refrigerator/Freezer, and 2 pantry cabinets for storing food supplies. Incontinence and other supplies were stored in separate cabinets.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE: 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)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: LILY AVENUE HOME
FACILITY NUMBER: 435200183
VISIT DATE: 10/02/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
At 1:08 PM, LPA inspected the exterior grounds of the facility. 3 ramps were observed in good condition and no obstructions and tripping hazards were observed in the passageways.

At 1:16 PM, LPA inspected the First Aid kit and observed it to contain required supplies. Emergency drills are conducted quarterly with the last drill documented on 09/19/2024.

At 1:24 PM, LPA was told that the facility serves residents based on the principles of Christian Science treatment. The facility staff do not have First Aid certification and no medication is administered to the residents. Christian Science facility staff are exempt from having current first aid certification. The facility has approved waiver for medical assessments, examinations, tests, health histories, or supervision.

At 1:38 PM, LPA completed the review of four resident and three staff records. All were observed to be complete.

At 1:40 PM, LPA observed three residents returning from their day program.

The following updated forms are requested to be submitted to CCLD by 10/09/2024:

  • LIC 500: Personnel Report
  • LIC 308: Designation of Facility Responsibility
  • LIC 400: Resident Cash Resources
  • LIC 999: Facility Sketch Floor Plan
  • Administrator Certificate
  • Surety Bond
  • Liability Insurance

Additionally, the Administrator will email updated ANS forms for three residents after getting signatures from conservators and service coordinators.

No deficiencies were cited during today's visit.

An exit interview was conducted. This report was reviewed with Amy Helleyer, Administrator and a copy of this report was left at the facility.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:

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
LIC809 (FAS) - (06/04)
Page: 2 of 2