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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320588
Report Date: 05/15/2026
Date Signed: 05/15/2026 11:43:33 AM

Document Has Been Signed on 05/15/2026 11:43 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:LILLY OF THE VALLEY DIVINE HOMEFACILITY NUMBER:
198320588
ADMINISTRATOR/
DIRECTOR:		NDUKWE, LILIANFACILITY TYPE:
740
ADDRESS:19009 WADLEYTELEPHONE:
(310) 347-2501
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 6CENSUS: 0DATE:
05/15/2026
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Lilian NdukweTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 05/15/26, at 9:00am, Licensing Program Analyst (LPA) Perry Scott conducted an announced visit to Lilly of the Valley Divine Home. LPA was greeted by applicant, Lilian Ndukwe. LPA explained the purpose of today’s pre-licensing inspection visit. The applicant has an administrator’s certificate (7031572740) which is valid from 10/10/2025 through 10/09/2027 for a Residential Care facility for the Elderly.

An application was submitted to Community Care Licensing Division (CCLD) on 03/13/25 in the initial license application for a Residential Care Facility for the Elderly. The applicant requested a capacity of six (6) ambulatory adults (aged 60 and over); with an approved hospice waiver for six (6) residents. A fire clearance was approved for six (6) ambulatory residents only.

Structure:

The home is a three (3) bedroom, two (2) bathroom, single-story home with an attached garage situated in a residential neighborhood. The home includes a living room, kitchen, and laundry area in the garage. The living area included table, sofa, couch, chairs, and a television. The kitchen has a refrigerator, stove, and microwave. The rear exterior is fenced throughout with a patio that includes a table, and chairs. The passageways in the backyard has ongoing construction that needs to be removed prior to licensing.

Report Continued On LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Perry Scott
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: LILLY OF THE VALLEY DIVINE HOME
FACILITY NUMBER: 198320588
VISIT DATE: 05/15/2026
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Bedrooms for Residents: The home has three (3) bedrooms. All rooms include two (2) full-size beds, one (1) chair, one (1) night stand, and table lamps. All bedrooms are equipped with ceiling lighting, and a dresser in one room. All rooms have closets with ample storage space. Bedrooms #1 and #2 are missing a chest of drawers in each room.

Bedrooms for Staff: There is no bedroom designated for live-in staff.

Bathrooms: The home has two (2) bathrooms. All bathrooms have a working toilet, washbasin, shower/tub with grab bars, and non-skid mats.

Linens & Hygiene Supplies: Beds have the required linen supplies which include pillowcases, mattress pads, fitted sheets, blankets, and bedspreads. An adequate supply of linen is stored in the hall storage area.

Emergency Phone Numbers, Exit Plan & Menu:

The emergency disaster plan is posted along with the exit plan. There is one (1) fire extinguisher located in the kitchen area. The facility has land line telephone located in the living room. The applicant has submitted a mitigation plan.

Food Service:

Dishes, cups, and flatware are stored in the kitchen cabinets, inspected, and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in a locked cabinet. Food supply is adequately stored in kitchen cabinets and consists of can and other dry goods. The facility has nonperishable foods for a minimum of one week but does not have any fresh perishable foods for a minimum of two days that were observed.

Smoke Detectors:

Smoke and carbon monoxide detectors are located throughout the interior space and bedrooms and are working properly.

Report Continued On LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Perry Scott
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: LILLY OF THE VALLEY DIVINE HOME
FACILITY NUMBER: 198320588
VISIT DATE: 05/15/2026
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Toxins & Kitchen: All toxins are locked and stored in the supply closet.

Stove burners and oven were not working because the home needs to have the gas turned on. Washer and dryer were working. There is one (1) refrigerator in the kitchen. The refrigerator measured a temperature of at least 45 degrees Fahrenheit for appropriate food storage. The home is equipped with central air and heating.

Water Temperature: The hot water temperature could not be measured because the home needs to have the gas turned on.

Medications, First-Aid Kit & Book:

First aid kit was stored in the supply closet but was missing an approved first aid manual. The first aid kit contained the following: thermometer, tweezers, scissors, antiseptic, bandages, and gauze medication cabinet that is locked and inaccessible to residents. The residents’ medications will be stored in a locked supply closet.

Resident & Staff Files, Reading Material, Games:

Records for staff and residents will be stored in a safe in the supply closet.

The home has board games, books, magazines, and other recreational materials for the residents.

Pool/Jacuzzi & Pets: There are no pets, jacuzzi, or pool at the home.

Fire clearance: A fire clearance inspection was conducted on 04/17/2026 and approved for a capacity of six (6) ambulatory residents only.

LPA did not observe pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency on the front and back exits.

Report Continued On LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Perry Scott
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: LILLY OF THE VALLEY DIVINE HOME
FACILITY NUMBER: 198320588
VISIT DATE: 05/15/2026
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Component III:

LPA and the applicant completed the Component III PowerPoint presentation, which gives an overview of what to expect while running a residential care Facility for the Elderly.

During the pre-licensing inspection there were items observed which do not comply with applicable laws and regulations. The following items require a follow up inspection for verification of correction before being licensed:

· Gas line needs to be turned on prior to licensing.

· Bedrooms #1 and #2 needs to have a chest of drawers.

· Bedroom #2 has a broken mirror on the closet door that needs to be replaced.

· First aid manual is required.

· A whole in the garage above the washer and dryer needs to be fixed.

· Remove broken pots/bricks and on-going construction material in the backyard and on the side of the house.

· Home needs at least a two-day supply of perishable food.

Pre-Licensing is not complete, and this facility has deficiencies which require a subsequent visit for proof of correction.

The department will submit a copy of this Facility Evaluation Report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

An exit interview was conducted, and a hard copy of this Facility Evaluation Report has been furnished to the applicant, Lilian Ndukwe.

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Perry Scott
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
LIC809 (FAS) - (06/04)
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