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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803267
Report Date: 09/17/2021
Date Signed: 09/21/2021 08:47:32 AM

Document Has Been Signed on 09/21/2021 08:47 AM - 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:LILY'S CARE HOME, LLCFACILITY NUMBER:
486803267
ADMINISTRATOR:MARILOU C MCCOLLOMFACILITY TYPE:
740
ADDRESS:702 MUSTANG COURTTELEPHONE:
(707) 207-3335
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 3DATE:
09/17/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Lily Bonifacio, caregiverTIME COMPLETED:
04:31 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to Lily's Care Home, LLC for the purpose of a case management inspection. LPA met with Lily Bonifacio, caregiver.
LPA previously spoke with Lily Bonifacio on 09/15/2021 regarding selling the property and closing the business. Lily stated the property was been sold and the sale is not in escrow yet. Licensee Isagani Bonifacio will be closing Lily's Care Home facility.
LPA toured and inspected the facility. LPA advised licensee Isagani Bonifacio (Lily's husband) they must have control of the property if Lily's Care Home plans to continue operating until the applicant/owner of the property is licensed by CCL. Licensee understands they are responsible for the facility and the care, safety, and supervision of the residents. LPA discussed with Lily the review of the secretary of state Limited Liability Company (LLC) indicated Lily's Care Home, LLC is suspended. Lily stated this is due to their taxes not being completed yet, but the necessary documents and fees have been submitted.

LPA requested the following to be submitted to Community Care Licensing (CCL):
    · Weekly updates from licensee regarding closure of the facility by email or phone
    · Complete Facility Closure Plan
    · LIC 9020
    · Copies of Letter of notification to resident’s families that the property has been sold, with date of closure for Lily’s Care Home
    · Copies of 60-day eviction letters (per regulation) issued to residents in care

Exit interview conducted with Lily Bonifacio, whose signature on this document confirms receipt.
Due to printer malfunction, this report was emailed to licensee.
No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2021
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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