<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005944
Report Date: 02/13/2023
Date Signed: 02/13/2023 02:16:05 PM

Document Has Been Signed on 02/13/2023 02:16 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
ORANGE & INLAND A/SC, 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: 4DATE:
02/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Tanimowo Oshodi, House ManagerTIME COMPLETED:
02:45 PM
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
Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into the facility by direct care staff. LPA met with Tanimowo Oshodi, House Manager and explained the nature of the visit.

LPA Martinez accompanied by house manager began the tour of the inside and outside of the facility. There are four clients in care and there is no active covid case in the facility. There is a sign-in procedure in place and LPA was checked in with temperature check. LPA observed two clients in living room upon entry. LPA observed required department postings, covid precautionary postings in the facility as well as hand washing signs throughout the facility. The facility has an Mitigation Plan on file with CCLD. Facility has required Emergency Disaster Plan posted. The facility is equipped with sufficient hand hygiene supplies, cleaning and disinfecting provisions. LPA observed hand sanitizers for use throughout the facility. Facility has an emergency food and water supply. Personal protective equipment (PPE) supply is available. All bathrooms observed to have a supply of soap, toilet paper and paper towels. LPA toured the client’s bedroom, all bedrooms observed to have all required components. Facility has a secure location for client’s medication, and it was observed there was a 30 day supply of medication for clients. LPA toured the outside of the facility and observed shaded seating areas for clients use.

Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with the facility representative and a copy of this report was provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE:
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1