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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005944
Report Date: 03/06/2024
Date Signed: 03/06/2024 10:04:47 AM

Document Has Been Signed on 03/06/2024 10:04 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
ORANGE COUNTY ASC, 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:
03/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:08 AM
MET WITH:Tani Oshodi - AdministratorTIME COMPLETED:
10:20 AM
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Licensing Program Analyst (LPA) Dwayne Mason Jr arrived at the facility unannounced for the purpose of
conducting a required annual inspection. LPA was greeted and granted entry into facility by DSPs Aaron Obi-ijomah and Emmanuel Ajayi. House Manager/Administrator Tani Oshodi joined the inspection at approximately 9:15am.

The facility is a one-story home with four client bedrooms, two bathrooms, kitchen, dining room, living room,
backyard and attached 2-car garage. Facility appears clean, safe and sanitary. LPA noted three clients were away at day program. The facility has all required elements for the client rooms, however, due to behaviors, one client's clothing is stored in the garage. All rooms have a bed, chair, closet space and ample lighting. Facility has extra linens for clients in the hallway closet. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water in both bathrooms measured between 105 degrees Fahrenheit and 120 degrees Fahrenheit. LPA observed facility has emergency food and water supply. LPA observed the fire extinguisher is fully charged as indicated by the arrow pointing to the green zone on the meter. LPA observed knives to be locked up in the kitchen. Toxins and chemicals are locked up in a cabinet in the garage. Medication for each client is kept locked in a cabinet near the dining room. The backyard has a shaded seating area. LPA reviewed staff files, client files, client medication and client P&I. LPA interviewed one client and one staff member. LPA issued three technical assistances to advise the facility maintain the LIC9282 and 610D at facility and the facility purchase a thermometer specifically meant to measure water.

Based on today's inspection, no deficiencies were noted. An exit interview was conducted with the House Manager an a copy of this report was provided.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2024
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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