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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603155
Report Date: 11/15/2021
Date Signed: 11/15/2021 05:07:57 PM

Document Has Been Signed on 11/15/2021 05:07 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:LILAC CHATEAU 1FACILITY NUMBER:
374603155
ADMINISTRATOR:WITHERS, KIMBERLYFACILITY TYPE:
740
ADDRESS:9718 EUCALYPTUS COURTTELEPHONE:
(619) 312-1494
CITY:SANTEESTATE: CAZIP CODE:
92071
CAPACITY: 6CENSUS: 4DATE:
11/15/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:39 PM
MET WITH:Licensee, Kimberly WithersTIME COMPLETED:
01:32 PM
NARRATIVE
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Licensing Program Analyst (LPA), Kristina Ryan conducted a case management visit to cite for a deficiency observed while completing a records review for a complaint. LPA met with Licensee, Kimberly Withers, and discussed the purpose of the visit.

While reviewing records for a complaint, LPA found that Resident 1 (R1) was admitted and retained with a diagnosis and symptoms of a contagious infection. Interviews with facility staff revealed that the staff were aware that (R1) had a history of this infection, and symptoms of the infection began the same day that R1 moved in.

A deficiency is being cited pursuant to Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on an LIC 809-D.

An exit interview was conducted, and this report was discussed with the licensee. A copy of the report, LIC 809-D, and Licensee/Appeal Rights (LIC 9058 01/16) will be emailed to the licensee following the visit. Acknowledgement of receipt of the documents is requested upon receipt
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Kristina Ryan
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2021
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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Document Has Been Signed on 11/15/2021 05:07 PM - It Cannot Be Edited


Created By: Kristina Ryan On 11/09/2021 at 08:47 AM
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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LILAC CHATEAU 1
FACILITY NUMBER: 374603155

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/09/2021
Section Cited
CCR
87615(a)(4)

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87615 Prohibited Health Conditions (a) (4) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: Staphylococcus aureus ("staph") infection or other serious infection. This requirement was not met as evidenced by;
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Licensee will review 87209- Program Flexibility and will provide training to staff on prohibited health conditions and exception request documentation. Licensee will submit training topics and staff sign in sheet to LPA by December 10, 2021.
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Based on record review and interviews, the licensee did not ensure, that one out of four residents, did not have a prohibited health condition. This posed a potential Health risk to persons 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:Simon Jacob
LICENSING EVALUATOR NAME:Kristina Ryan
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2021


LIC809 (FAS) - (06/04)
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