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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002027
Report Date: 04/13/2023
Date Signed: 04/13/2023 03:20:31 PM


Document Has Been Signed on 04/13/2023 03:20 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



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: 21DATE:
04/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Administrative Assistant; Naitasha PeermanTIME COMPLETED:
03:30 PM
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Licensing Program Analysts (LPAs) Ivan Avila and Kerry Hiratsuka arrived at the facility unannounced on 4/13/23 to conduct a Annual Inspection. LPAs met with Administrative Assistant Naitasha Peerman and were met later in the visit with Jennifer Boss and explained the purpose of the visit.

LPAs toured the interior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, 5 resident bedrooms, bathroom, kitchen, and medication room. LPAs observed the facility to be clean, in good repair and odor-free and each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids and 20-second hand-washing poster. LPAs observed sufficient 2+day perishable and 7+day non-perishable supply of food and sharps to be locked. In the areas toured no immediate health, safety, or personal rights violations were observed.

Resident care needs appear to be met.

LPAs compared ordered medication to medication being given for 1 client and found no discrepancies. LPAs reviewed 3 staff files and found them to contain current First Aid and training. And review 3 resident files.

Several topics discussed.

No deficiencies are being cited.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023
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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