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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005944
Report Date: 03/11/2022
Date Signed: 03/11/2022 12:02:24 PM

Document Has Been Signed on 03/11/2022 12:02 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:
03/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:House Manager Tanimowo OshodiTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by House Manager Tanimowo Oshodi and explained the reason for the visit today. LPA was temperature checked a screened before entering the facility. Administrator (AD) Tammy Shindy was not present for todays visit, but has a current Administrators certificate that expires 9/25/23. LPA observed all required postings on the wall throughout the facility. House Manager Tanimowo led the tour of the facility. There were three clients present during the visit and another client at day program. At 10:40 AM LPA began the tour with the house manager and we started in the garage. All cleaning supplies, and hazardous chemicals are locked in the garage above the washer and dryer and in a locked cabinet. The garage was clear and free of clutter. LPA observed emergency kits present in the garage and a adequate supply of extra PPE: surgical face mask, gloves, gowns, hand sanitizer, and COVID test kits. From the garage we went to the backyard area. There was a self closing self latching gate. There is a shaded patio area with a table with a sun shade, and chairs for the clients to enjoy. LPA observed a mini basketball stations, and an area where the clients were painting the previous day. There were no bodies of water observed. Next LPA observed the kitchen area. The kitchen was clean and well organized. The stove was clean and all four burners were operational. All knives and sharp objects were locked under the sink. The facility has a two day supply of perishable food items and seven day supply of nonperishable food items. No hazardous chemicals are stored in the kitchen. Near the dining room there is a locked medications cabinet. There was a first aid kit equipped with the necessary elements located in the locked medication cabinet. LPA checked client rooms and bathrooms. Client rooms have the necessary requirements. Bathrooms were operational and clean. In Bathroom #1 LPA measured the water temperature at 117.8 degrees Fahrenheit, and in Bathroom #2 water was measured at 117.3 degrees Fahrenheit. Wired smoke detectors were tested and were operational. LPA consulted the House Manager on the importance of always having an adequate supply of emergency food and water available at the facility. No deficiencies are being cited during todays visit. An exit interview was conducted and a copy of the report was provided to House Manager Tanimowo Oshodi.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2022
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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