185002760-5-1-2024-59-AS-JBOS-D4UPH8-20240501111931

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 185002760
Report Date: 05/01/2024
Date Signed: 05/01/2024 11:19:39 AM

Document Has Been Signed on 05/01/2024 11:19 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	LASSEN LIFE SKILLS INC.		FACILITY NUMBER:	185002760
ADMINISTRATOR/ DIRECTOR:	BROWN, CHRISTINA		FACILITY TYPE:	775
ADDRESS:	475-340 SAN FRANCISCO ST		TELEPHONE:	(530) 257-7799
CITY:	SUSANVILLE	STATE: CA	ZIP CODE:	96130
CAPACITY: 45		CENSUS: 33	DATE:	05/01/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Administrator- Lisa Rainey		TIME VISIT/ INSPECTION COMPLETED:	11:30 AM

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On 05/01/2024, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator, Lisa Rainey, and explained the purpose of the visit.

LPA Boyles and Administrator toured facility together to ensure health and safety of residents in care. LPA observed the facility to be clean, in good repair and odor-free.

Areas toured include but are not limited to: common areas, and common restrooms. LPA observed each bathroom be in working order and to have the necessary paper towels. In the bathroom under the sink there were chemicals stored accessible to residents. In the hallway chemicals were stored accessible to residents.

The facility has a plethora of activities and supplies for scheduled activities.
LPA observed three (3) fire extinguishers, fire detectors, and carbon monoxide detectors.

LPA reviewed a total of five (5) residents' files and five (5) staff files which contained all of the required documentation. The facility had a completed emergency disaster plan and monthly emergency disaster drills for the LPA to review. LPA observed a complete first aid kit ready for emergency use.

Several topics were discussed.

Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code.

An exit interview was conducted, and Plans of Corrections were reviewed and developed collaboratively. Acopy of this report, LIC 809-D, and Appeal Rights were discussed and provided.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

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 05/01/2024 11:19 AM - It Cannot Be Edited

Created By: Jaynae Boyles On 05/01/2024 at 11:08 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LASSEN LIFE SKILLS INC.	FACILITY NUMBER: 185002760
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

82087(a)(3)

Buildings and Grounds

(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that chemicals were stored accessible to residents in three locations at the facility which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/22/2024
	Plan of Correction
1 2 3 4	Administrator will provide a training to the facility staff informing of the importance of storing chemicals inaccessible to residents. Adminstrator will send the LPA proof of the training was completed.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Lauren Crocker

LICENSING EVALUATOR NAME:

Jaynae Boyles

LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

LIC809 (FAS) - (06/04)

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