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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340311442
Report Date: 01/23/2025
Date Signed: 01/23/2025 01:42:28 PM

Document Has Been Signed on 01/23/2025 01:42 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:LILLIE CARE HOMEFACILITY NUMBER:
340311442
ADMINISTRATOR/
DIRECTOR:		ARLYNN WILLIAMSFACILITY TYPE:
740
ADDRESS:6831 GOLF VIEW DRIVETELEPHONE:
(916) 391-2302
CITY:SACRAMENTOSTATE: CAZIP CODE:
95822
CAPACITY: 6CENSUS: 3DATE:
01/23/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Shaquita HaywoodTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On 1/23/25 Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced plan of correction (POC) to ensure the Plan of correction has been completed from previous citation.

LPA observed the facility is still in process of completing POCs and have submitted documentation to address FAR issued by Alta Regional Center.

LPA did observe that previously observed paint cans and items stored under a table on the patio are still present after LPA Gould issued an advisory note (technical violation) for the items not stored inaccessible to clients in care.

LPA reminded the newly appointed administrator to complete all POCs by the POC due date.

Per California Code of regulations, Title 22 The following deficiency is cited during today's inspection.

Exit interview conducted and a copy of this report and appeal rights were left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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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Document Has Been Signed on 01/23/2025 01:42 PM - It Cannot Be Edited


Created By: Kevin Gould On 01/23/2025 at 01:24 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LILLIE CARE HOME
FACILITY NUMBER: 340311442

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2025
Section Cited
CCR
87309(a)

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Storage Space: Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to
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Licensee agrees to dispose of or store items inaccessible to residents by the POC due date: 1/31/25.
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residents are in locked storage and are not left unattended if outside the locked storage. This requirement was not met as evidenced by LPA observations of paint cans stored in the back yard under an outdoor table which 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.
SUPERVISOR'S NAME:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2025


LIC809 (FAS) - (06/04)
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