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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 185002760
Report Date: 06/02/2023
Date Signed: 06/02/2023 11:32:03 AM

Document Has Been Signed on 06/02/2023 11:32 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:LASSEN LIFE SKILLS INC.FACILITY NUMBER:
185002760
ADMINISTRATOR:BROWN, CHRISTINAFACILITY TYPE:
775
ADDRESS:475-340 SAN FRANCISCO STTELEPHONE:
(530) 257-7799
CITY:SUSANVILLESTATE: CAZIP CODE:
96130
CAPACITY: 45CENSUS: 45DATE:
06/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Chris BrownTIME COMPLETED:
11:45 AM
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06/02/2023 09:00 AM Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Lisa Rainy Administrator and explained the purpose of the visit.


LPA Benson and the administrator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to common areas, four (4) bathrooms, kitchen, storage areas and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. Staff and resident files were reviewed.

Common area was clean and in good repair. Bathrooms were clean and in good repair. Kitchen was clean and in good repair.

First aid kit fully stocked and ready for emergency use. Fire extinguisher fully charged with exp. 05-10-2023. Smoke detectors are all operational. Hot water temperature measured within required Title 22 regulations of 105 degrees F and 120 degrees F. All employees requiring background checks are cleared. All required postings are displayed within facility.

No pools/bodies of water are on premises. No firearms are on premises. Last disaster drill was conducted and documented on 04-20-23, the facility has been conducting drills once every month.

No deficiencies are being cited as a result of today’s inspection.



Exit interview conducted and copy of report was provided to administrator Lisa Rainy.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2023
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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