435202976-5-27-2026-26-AS-RMAO-DURJRH-20260605071647

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202976
Report Date: 05/27/2026
Date Signed: 05/27/2026 10:54:26 AM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/01/2026 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20260501153220

FACILITY NAME:	LILLY'S CARE HOME		FACILITY NUMBER:	435202976
ADMINISTRATOR:	LI, LILLY		FACILITY TYPE:	740
ADDRESS:	329 EL PORTAL WAY		TELEPHONE:	(408) 687-5448
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95119
CAPACITY:	6	CENSUS: 6	DATE:	05/27/2026
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Administrator Lilly Li		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Facility staff providing night shift does not have first aid/CPR training

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegations. LPA met with Administrator Lilly Li

On May 1, 2026, the Department received a complaint alleging Facility staff providing night shift does not have first aid/CPR training

On May 7, 2026, the Department interviewed Administrator (ADM) Lilly Li. ADM stated all her employees have completed their first aide. ADM stated she would provide a copy of the fist aide to LPA.

Page 1 Out of 2.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 6

Control Number 26-AS-20260501153220

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: LILLY'S CARE HOME	FACILITY NUMBER: 435202976
	VISIT DATE: 05/27/2026

NARRATIVE

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On May 7, 2026, Licensing Program Analyst Manuel Monter reviewed/audited all staff members 6 Out of 6 staff, including Administrator Lilly Li has completed and current first aid training.

The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

Page 2 Out of 2. End of Report.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/01/2026 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20260501153220

FACILITY NAME:	LILLY'S CARE HOME		FACILITY NUMBER:	435202976
ADMINISTRATOR:	LI, LILLY		FACILITY TYPE:	740
ADDRESS:	329 EL PORTAL WAY		TELEPHONE:	(408) 687-5448
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95119
CAPACITY:	6	CENSUS: 6	DATE:	05/27/2026
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Administrator Lilly Li		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Facility staff is not able to communicate due to English barrier in emergency situations

INVESTIGATION FINDINGS:

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On May 1, 2026, the Department received a complaint alleging Facility staff is not able to communicate due to English barrier in emergency situations. Its been alleged the night shift staff is not able to communicate due to English barrier in emergency situations.

On May 7, 2026, Licensing Program Analyst Manuel Monter interviewed staff S1 and S2. (During the course of this interview, S1 would not respond to questions posed by LPA. S1 would activate the text to speech when LPA was talking and allow the translation app to translate. S1 would then use the text to speech, speaking in mandarin to his/her translation app, which translated to English.)

LPA asked S1 if he/she knew the address of the home. S1 made multiple attempts via the translation app on his/her phone. LPA had to re-phrase the question 3 times for S1 to understand the question. S1 was able to answer the question. (Continued on LIC9099-C) Page 1 Out of 3.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 26-AS-20260501153220

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: LILLY'S CARE HOME	FACILITY NUMBER: 435202976
	VISIT DATE: 05/27/2026

NARRATIVE

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LPA asked S1 how many residents live in the home. S1 made multiple attempts with his/her translation app. S1 was not able to answer the question. LPA had to re-phrase the question multiple times for S1 to understand the question. S1 was then able to answer, stating there are 6 residents in the home.

LPA asked S1 what he/she would do if a resident sustained a fall. LPA asked S1 not to use the translation app. S1 gestured that he/she wasn’t able to answer. S1 then used his/her translation app. S1 responded via translation app that he/she would call the hospital immediately. LPA asked S1 if he/she could show LPA what he/she would say when contacting 911 and how he/she would do it. S1 stated he/she uses his/her translation app.

LPA made multiple attempts to ask S1 what he/she would say to emergency services in response to a fall or a fire, but S1 wasn’t able to provide an answer besides reiterating via translation app that he/she would call the hospital calling the hospital immediately or call the administrator.

LPA asked S1 if paramedics asked for Polst, would he/she know what that is. S1 wasn’t able to respond to question using his/her translation app. LPA brought a residents centrally stored medication record to S1. LPA asked S1, if emergency responders asked, would he/she be able to answer what medications a resident was taking. S1 was not able to answer the question.

On May 7, 2026, Licensing Program Analyst Manuel Monter interviewed Administrator Lilly Li. LPA asked ADM if staff S1 can communicate with emergency responders. ADM stated she is the one who communicates with emergency responders. LPA informed ADM based on interview conducted with S1, he/she was not able to show LPA how he would communicate with emergency services during an emergency. ADM stated she lives 5 minutes away from the home. ADM stated if anything happens, S1 will contact her first. LPA informed ADM that her staff needs to be able to have the ability to communicate with emergency services.

LPA informed ADM that there a multitude of possibilities where the ADM isn’t available. LPA informed ADM that the staff at the home needs to be able to and have the ability to contact 911 if an emergency occurs. ADM agreed that this could be an issue.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 26-AS-20260501153220

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: LILLY'S CARE HOME	FACILITY NUMBER: 435202976
	VISIT DATE: 05/27/2026

NARRATIVE

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ADM stated because S1 isn’t able to verbally communicate, she would be the one who would do the communicating. ADM stated during an emergency situation, S1 would contact her. ADM acknowledged S1, being the only staff member in the home, during NOC shift, and not being able to communicate without the assistance of ADM, who doesn’t live in the home, is an issue.

On May 18, 2026, Licensing Program Analyst Manuel Monter interviewed staff S3. S3 was able to answer questions posed by LPA and was able to described what he/she is supposed to do in emergency situations.

Based on interviews and documents review the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED.

Deficiencies cited during today's visit. See LIC9099-D. This report was reviewed with Administrator Lilly Li. Appeal rights were provided.

Page 3 Out of 3. End of Report.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2026

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 26-AS-20260501153220

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: LILLY'S CARE HOME	FACILITY NUMBER: 435202976
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/27/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/03/2026 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements -General (a) Facility personnel shall at all times be … competent to provide the services necessary to meet resident needs. … additional staff for the provision of adequate services. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Licensee stated to she will submit a written plan of action on how she will ensure there is at least 1 staff member in the facility, who is able to communicate with emergency services during an emergency. Licensee stated she will submit the plan of action by POC due date June 3, 2026.
	8 9 10 11 12 13 14	Based on interviews conducted, staff S1 was unable to demonstrate how he/she would be able contact and communicate with emergency services during an emergency. ADM acknowledged S1, being the only staff member in the home, during NOC shift, and not being able to communicate	8 9 10 11 12 13 14	(Continued) without the assistance of ADM, who doesn’t live in the home. This poses a potential health, safety and personal rights risk to residents in care.
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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.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2026

LIC9099 (FAS) - (06/04)

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