374604980-10-20-2025-08-AS-RHAL-DMMPKY-20251020112356

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604980
Report Date: 10/20/2025
Date Signed: 10/20/2025 11:28:38 AM

Document Has Been Signed on 10/20/2025 11:28 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	LILOS TENDER SENIOR CARE INC.		FACILITY NUMBER:	374604980
ADMINISTRATOR/ DIRECTOR:	MOLINA, STEPHANIE		FACILITY TYPE:	740
ADDRESS:	7949 EASTRIDGE RD		TELEPHONE:	(818) 284-2502
CITY:	LA MESA	STATE: CA	ZIP CODE:	91941
CAPACITY: 6		CENSUS: 0	DATE:	10/20/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Ana Petrosyan, Licensee Stephanie Molina, Administrator		TIME VISIT/ INSPECTION COMPLETED:	11:45 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	LPA conducted a pre-licensing visit for Component III for change of location. LPA was allowed entry by the Licensee. LPA identified herself and disclosed the purpose of the visit. A comprehensive tour of the facility, both indoors and outdoors, was conducted. At the time of the visit, no residents were in care at the current facility. Residents have not been transferred from the old facility until the end of the month. The licensee agreed to contact LPA when residents move in for post-Licensing inspection. All required postings were observed in prominent locations, including the Emergency Disaster Plan, Complaint Poster, Personal Rights, and the Let-Us-No Poster. Emergency phone numbers and the Administrator’s contact information were visible. Smoke and carbon monoxide detectors were tested and found operational. Fire extinguishers were fully charged, tagged, and properly mounted. Hot water temperature was tested and measured between 105°F – 120°F. Continued on 809C

NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Renita Hall
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2025

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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LILOS TENDER SENIOR CARE INC.	FACILITY NUMBER: 374604980
	VISIT DATE: 10/20/2025

NARRATIVE

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The first aid kit was present and fully stocked. Medications, cleaning supplies, and sharps were observed to be securely locked and inaccessible to residents. Adequate lighting, appropriate furniture, and clean, safe conditions were observed in all rooms and common areas. Kitchen and food storage areas were inspected, and a sufficient supply of non-perishable items was present.

Component III topics, including resident personal rights, medication management, reporting requirements, and staff training, were reviewed with the Licensee. The Licensee clearly understood Title 22 regulations, record-keeping requirements, and emergency procedures. LPA discussed ongoing compliance requirements and answered questions related to day-to-day operations and licensing expectations.

No deficiencies were cited during this visit. The facility appears ready for licensure and may begin accepting residents upon final approval by the Department. An exit interview was conducted with the Licensee, to whom a copy of this report and the Applicant/Appeal Rights (LIC9058) were provided.

NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Renita Hall
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2025

LIC809 (FAS) - (06/04)

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