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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002027
Report Date: 03/08/2022
Date Signed: 03/08/2022 03:24:05 PM


Document Has Been Signed on 03/08/2022 03:24 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:LAVENDER HILLS ASSISTED LIVING IIFACILITY NUMBER:
455002027
ADMINISTRATOR:BOSS, JENNIFERFACILITY TYPE:
740
ADDRESS:1750 COLLYER DRIVETELEPHONE:
(530) 247-0749
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:25CENSUS: 15DATE:
03/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:08 PM
MET WITH:Jennifer Boss, AdministratorTIME COMPLETED:
03:39 PM
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3/08/2022 2:00 p.m Licensing Program Analyst (LPA) Dawn Keane and Misty Valencia, arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Jennifer Boss, Administrator (AD) and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA contacted AD and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical mask. Additionally, LPA Keane and Valencia were screened by AD/staff person.

LPA Keane, Valencia and the AD toured facility to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, two (2) bathrooms, three (3) bedrooms, kitchen, storage areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Keane and the AD completed the infection control domain and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of report was given to AD.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Dawn KeaneTELEPHONE: (530) 895-2660
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022
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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