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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005944
Report Date: 08/24/2021
Date Signed: 08/24/2021 04:29:39 PM

Document Has Been Signed on 08/24/2021 04:29 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:LAVENDER GUEST HOMEFACILITY NUMBER:
306005944
ADMINISTRATOR:SHINDY, TAMMYFACILITY TYPE:
735
ADDRESS:1872 LOTUS PLACETELEPHONE:
(714) 351-1012
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY: 4CENSUS: 3DATE:
08/24/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:House Manager, Tanimowo OshodiTIME COMPLETED:
04:40 PM
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On this day Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced Case Management visit to check on the Health and Safety and welfare of Clients in the facility. LPA Tirre met with House Manager Tanimowo Oshodi. LPA visited the facility to follow up on an Special Incident Report regarding a client (C1).

During Visit LPA toured facility with House Manager Oshodi. LPA toured Kitchen, living room, client bedrooms, bathrooms, garage and back yard patio. LPA observed facility to have working lights and lamps in each room. Kitchen Stove was operational as LPA observed Staff cooking hamburgers for client. Client bedrooms met department guidelines. LPA observed bathrooms to have working water Basin, toilet and shower. Water temperature measured between 111.3 to 112.6 degrees Fahrenheit. Facility has ample supply of hygienic supplies such as soap, shampoo, conditioner, toothpaste, mouthwash and lotion. Facility has fridge and pantry with ample supply of perishable and non-perishable foods. Facility has emergency food and water. During visit facility had 2 staff on hand.

LPA Observed clients eating meals and snacks in the kitchen and relaxing in bedrooms. LPA observed staff engaged with clients. LPA engaged in talking with clients and clients engaged in conversation. Clients were well groomed in appearance. No observations of neglect.

LPA requested pertinent documents regarding C1.

During today's visit, no deficiencies were observed and the facility appears to be in substantial compliance with Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with House Manager and a copy of this report, along with the LIC 811, was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2021
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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