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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005944
Report Date: 02/05/2025
Date Signed: 02/05/2025 10:26:24 AM

Document Has Been Signed on 02/05/2025 10:26 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:LAVENDER GUEST HOMEFACILITY NUMBER:
306005944
ADMINISTRATOR/
DIRECTOR:		SHINDY, TAMMYFACILITY TYPE:
735
ADDRESS:1872 LOTUS PLACETELEPHONE:
(714) 351-1012
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY: 4CENSUS: 3DATE:
02/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Tanimowo Oshodi, Administrator (AD) TIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Staff #1 at 8am. During today’s visit, LPA met with Tanimowo "Tani' Oshodi, Administrator (AD).

The facility is a level 4g, four bedroom, two bathroom, single story home with an approved fire clearance of four ambulatory. The facility currently has a census of three clients in care. At time of entry, LPA observed one client reclining in the living area, two clients had left for Adult Day Program and the fourth client is currently on vacation.

During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in two of two client bathrooms, and testing auditory devices. The hot water temperature measured between 116.7 to 117.6 degrees Fahrenheit and all smoke detectors were operational. Sharps and cleaning supplies were secured. Client bedrooms had the required linens and furnishings. The fire extinguishers were charged and were serviced on September 1, 2024 The facility’s last fire drill was conducted on January 13, 2025.

The exterior had a shaded area for clients and many fruit trees that clients like to pick from such as: orange, grapefruit, lemon, lime and tangerines. There is a self-latching gate that remains unlocked. Clients are active in sports such as basketball, bowling and swimming and enjoy shopping in the community.

LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand with ample water. Facility had all the required elements in the First Aid Kit; including the First Aid Manual. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed.
(Continued on LIC 809)
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: LAVENDER GUEST HOME
FACILITY NUMBER: 306005944
VISIT DATE: 02/05/2025
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(Continued from LIC 809)

LPA reviewed two of two staff training and fingerprint records and conducted a complete review of client records. Client P&I records were reviewed and were accurate. LPA interviewed alert clients regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that Administrator has a current administrator certificate which expires on July 6, 2025.

Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. A LIC 9102TV was given for AD to include Admissions Agreements that comply with Title 22 Regulations. Clients have Regional Center Admissions Agreements on file. An exit interview was conducted with Tanimowo Oshodi, Administrator (AD) and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
LIC809 (FAS) - (06/04)
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