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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606341
Report Date: 09/26/2024
Date Signed: 09/27/2024 09:06:49 AM

Document Has Been Signed on 09/27/2024 09:06 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:LILY OF THE VALLEYFACILITY NUMBER:
197606341
ADMINISTRATOR/
DIRECTOR:		NATALIA L. ESPINOFACILITY TYPE:
740
ADDRESS:8618 BOTHWELL ROADTELEPHONE:
(818) 993-7800
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 6CENSUS: 3DATE:
09/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:14 AM
MET WITH:Rody EspinoTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analysts (LPAs) Mariana Agban and Michael Cava conducted an Annual Required visit and inspection of the facility. LPAs met with staff, and explained the reason for the visit. Administrator, Rody Espino was contacted by staff and arrived shortly after. At approximately 11:15 am, with the assistance of staff, LPAs took a tour of the physical plant. Required postings were observed in the entry area.

The smoke alarms are interconnected and battery-operated. There is a carbon monoxide detector that functions properly installed in the hallway between resident rooms.

Common Areas: This includes the living room dining areas were appropriately furnished and lighting was adequate. The living room has a television and comfortable furniture. Properly labeled medications were locked in one of the living room cabinets. The fireplace was observed with a screen and glass covering. There were no tools present. According to the Administrator, the fireplace is never in use. LPAs did not observe any keys or turn on the switch to operate the fireplace, accessible to residents at the time of the visit
Kitchen: The kitchen appliances and fixtures were functional. LPAs found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. LPAs observed fully stocked first aid kit and fire extinguisher in the kitchen with a purchase date of 07/11/24.

Bedrooms: There were four(4) bedrooms designated for residents' use. One (1) bedroom is designated for staff use. All four (4) bedrooms, in use by residents, were properly furnished with appropriate beddings and linens with sufficient lighting.

Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 111.4 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection. (Continue 809C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: LILY OF THE VALLEY
FACILITY NUMBER: 197606341
VISIT DATE: 09/26/2024
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Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. The outdoor area was free of hazards. There is a swimming pool that is fenced all around its parameters. The fence was at least five foot high with a gate, that is also five foot high. The gate was observed locked, making it inaccessible to residents to enter.

Resident Files: LPAs conducted a file review of resident records to ensure compliance of licensing forms.

Staff Files: LPAs also conducted a file review of staff records to ensure forms and training are up to date and compliant with licensing forms.

Medications: Medication and Medication Records were reviewed for proper documentation.

Temperature: Facility maintains a comfortable temperature of 77 degrees Fahrenheit

Garage: On 08/06/2024 the Licensee was cited for converting the garage to a room with a private bathroom without obtaining permits. During today's annual inspection, LPAs observed the room that was converted was demolished. Administrator confirmed that no staff or residents are residing in that room.


Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC809 (FAS) - (06/04)
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