455002027-6-18-2024-59-AS-KHOS-D6FT6E-20240621142701

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 455002027
Report Date: 06/18/2024
Date Signed: 06/18/2024 09:35:24 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/30/2024 and conducted by Evaluator Donna Gurriere

COMPLAINT CONTROL NUMBER: 59-AS-20240130141806

FACILITY NAME:	LAVENDER HILLS ASSISTED LIVING II		FACILITY NUMBER:	455002027
ADMINISTRATOR:	BOSS, JENNIFER		FACILITY TYPE:	740
ADDRESS:	1750 COLLYER DRIVE		TELEPHONE:	(530) 247-0749
CITY:	REDDING	STATE: CA	ZIP CODE:	96003
CAPACITY:	25	CENSUS: 22	DATE:	06/18/2024
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	NATASHA PEERMAN		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Insufficient staff/Lack of supervision.

INVESTIGATION FINDINGS:

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On 06/18/24 Donna Gurriere, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 01/30/24. LPA Gurriere met with Natasha Peerman, Asst. Administrator, and explained the purpose of the visit.

Insufficient staff/Lack of supervision.

During the interview process, the administrator and three staff persons were interviewed. Attempts were made to interview two other staff persons; however, they were not available. In addition, documents were obtained and reviewed to include the resident’s Physician’s Report and staff persons telephone numbers.

continued

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20240130141806

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 06/18/2024

NARRATIVE

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During the investigation, it was reported that paramedics arrived at the facility to follow up on a resident and stated that the staff person working, appeared to be disheveled. It was stated by the staff that were interviewed that they were not aware of the incident and overall, it was reported that there is sufficient staff during the nighttime shift to meet the needs of the residents.

Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above finding is Unsubstantiated.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

LIC9099 (FAS) - (06/04)

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