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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603571
Report Date: 08/21/2025
Date Signed: 08/21/2025 03:25:30 PM

Document Has Been Signed on 08/21/2025 03:25 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:LILY CREST MANOR, INCFACILITY NUMBER:
198603571
ADMINISTRATOR/
DIRECTOR:		SHINN, ANTHONY AFACILITY TYPE:
740
ADDRESS:900 N. ALEXANDRIA AVENUETELEPHONE:
(323) 661-1784
CITY:LOS ANGELESSTATE: CAZIP CODE:
90029
CAPACITY: 4CENSUS: 4DATE:
08/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Administrator Anthony ShinnTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
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License Program Analysts (LPA) Luis De Leon conducted an unannounced annual required visit. LPA met with Administrator Anthony Shinn. The purpose of today’s visit was explained. The facility is licensed to serve adults 60 years and over, of which two (2) may be bedridden. The licensee is approved for 2 hospice waivers. Residents are serviced by Frank D. Lanterman Regional Center.

The LPA use the Compliance & Regulatory Enforcement Tool (CARE) during today’s inspection. The visit consisted as follows:

FACILITY PHYSICAL PLANT
The facility is in a residential area and is made up of four (4) resident bedrooms and one (2) staff bedroom, two (2) full bathrooms for resident use and one (1) staff bathroom, living room, dining room, laundry room, front and backyard, and a detached car garage. There were no body of water observed in the property.

REVIEW OF FILES
Resident record review consisted of Admission Agreements, Identification and Emergency Info, Physicians Report, Consent Report, Individual Program Plan, Personal Rights, and Centrally Store Medication. Staff record review consisted of Personnel Report, Health Screening, Criminal Record Statements, Fingerprint Clearance, Training, First Aid and CPR.

Report continues on LIC 809C...
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Luis DeLeon
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2025
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LILY CREST MANOR, INC
FACILITY NUMBER: 198603571
VISIT DATE: 08/21/2025
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Observations during facility tour:
  • Bedrooms were furnished with a bedframe, dresser, lamps, and chairs. LPA observed that there was clean linen, bath towels, and personal hygiene with reasonable closet space available for residents.
  • Wall and floors are in good repair. Hallways were clean and free of obstructions.
  • Kitchen appliances were in working order and clean. There is sufficient two (2) days of perishables and seven (7) day supply of non-perishable food. Dining room has sufficient seating area. Weekly food menu is posted at facility.
  • Toilets, showers, and water faucets are found in compliance with Title 22 regulations for temperature and function. Restrooms were stocked and clean. The water temperature was tested and measured. It was found in compliance with Title 22 regulations between 105º and 120º F degrees.
  • Sharps are locked inside a kitchen drawer and inaccessible to residents. Also, disinfectants and cleaning supplies are locked and secured inaccessible to residents.
  • Smoke detectors were observed in all bedrooms and carbon monoxide detectors was observed in living room around kitchen area. One (1) fire extinguisher was observed and was fully charged with the last inspection on 8/30/24.
  • Last fire drill and disaster drill was conducted on 5/3/25. Earthquake drill was done on 5/3/25.
  • Front and back yards are free of hazards. Back yard has a shaded seating area for residents to enjoy.
  • The medications are centrally stored and locked in the staff room. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for all four (4) residents.
  • LPA conducted interviews with one staff. Two resident interviews were conducted while other residents were out in the community.
  • The facility provides various activities for residents to participate in day programs, community outings, watch TV, music, and going to the park.

Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were observed during the visit. Exit interview held and a copy of the report along was provided to the administrator.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Luis DeLeon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
LIC809 (FAS) - (06/04)
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