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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002027
Report Date: 04/15/2024
Date Signed: 04/15/2024 01:14:47 PM


Document Has Been Signed on 04/15/2024 01:14 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 17DATE:
04/15/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Administrator- Jennifer Boss TIME COMPLETED:
01:20 PM
NARRATIVE
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On 4/15/2024 Licensing Program Analyst (LPA) Jaynae Boyles arrived at the facility unannounced to conduct a case management to follow up on a recent AWOL at the facility. LPA met with facility Administrator Jennifer Boss and explained the purpose of the visit.

The incident occurred on 4/11/2024 where a resident, who was deemed unable to leave facility unassisted at around 4pm, had eloped in the afternoon without any staff knowing. While out the resident had an unwitnessed fall resulting in the resident sustaining a broken hip. A community member found the resident on the sidewalk and contacted 911. The facility was informed by resident's son later that afternoon at around 4:28pm.

As a result of the incident, the Department is issuing a citation on the attached LIC 809-D, per Title 22 Regulations. Also attached to the deficiency is an immediate civil penalty in the amount of $500, which is assessed for a violation of California Code of Regulations Section 87705(c)(4). The licensee was informed that an Enhanced Civil Penalty is under review and may be assessed at a future date according to Health and Safety Code 1569.49.

Exit interview conducted. A copy of the report has been issued. Appeal Rights provided. Jennifer Boss signature on this report acknowledges receipt of these reports.


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SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2024
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 2


Document Has Been Signed on 04/15/2024 01:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: LAVENDER HILLS ASSISTED LIVING II
FACILITY NUMBER: 455002027

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/16/2024
Section Cited
CCR
87705(c)(4)

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87705(c)(4) Care of Persons with Dementia-Licensees who accept and retain residents with dementia shall be responsible for ensuring: There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs.

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Licensee agrees to create and implement a policy and procedure to ensure accountability of individual staff to ensure they are conducting wellness checks. Policy due to CCL no later than COB on 04/16/2024
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Based upon observation and interview the Licensee failed to provide enough care staff to ensure the safety and health care needs of 1 of 1 residents who went AWOL.

This poses an immediate Health, Safety and/or Personal Rights risk to residents in care.
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Civil Penalty assessed in the amount of $500

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2024
LIC809 (FAS) - (06/04)
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