455002027-8-1-2025-59-AS-SBEN-DK5UM6-20250801154148

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 455002027
Report Date: 07/31/2025
Date Signed: 08/01/2025 03:41:56 PM

Document Has Been Signed on 08/01/2025 03:41 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 II		FACILITY NUMBER:	455002027
ADMINISTRATOR/ DIRECTOR:	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:	07/31/2025
TYPE OF VISIT:	Office	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:00 PM
MET WITH:	Administrator Jennifer Boss		TIME VISIT/ INSPECTION COMPLETED:	03:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	An non-compliance conference was conducted at 2:00pm on June 31, 2025, with Sacramento North Regional Office via Microsoft Teams. The purpose of this non-compliance conference meeting is to address a citation issued on 4/15/2024. The following Licensing staff were present: Sacramento North Regional Manager Alycia Rayner, Licensing Program Manager Lauren Crocket, Licensing Program Analyst Sarah Benson. The following facility representatives were present: Licensee Janet Coulter, Administrator Jennifer Boss, Administrator Naitasha Peerman. The following topics were discussed during today's meeting: Summary of Complaint filed against this facility. Summary of Complaints filed against this facility. Care of Persons with Dementia, Elopement Safety issues Staff training Personal Rights of Residents in All Facilities Care for Persons with Dementia TSP offered as a resource Door chime, who answers Activities offered Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Lauren Crocker
NAME OF LICENSING PROGRAM ANALYST: Sarah Benson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LAVENDER HILLS ASSISTED LIVING II	FACILITY NUMBER: 455002027
	VISIT DATE: 07/31/2025

NARRATIVE

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Compliance Plan:

The Licensee will provide a document with the programs implemented with regards to:

1. Ensuring how staff plan to prevent eloping.,
2. A list of preventative steps taken and when implemented.
3. Training's and ongoing training's, how often.
4. Quality assurance, how management is ensuring plan is actually happening,
5. Process to ensure staff are adhering to the policy.
6. List of the processes.

The licensee understands and acknowledges that the Department, at its discretion, will make unannounced case management visits to monitor the licensee’s compliance with this Compliance Plan.

Completing the Non-Compliance Conference does not deprive the Department of its authority to take formal legal action under the Health and Safety Code if such action is deemed necessary by the Regional Manager.

This conference does not in any manner excuse past problems or resolve the Department’s case against the licensee if the problems are not corrected. The Non-Compliance Conference may be the last step prior to initiating administrative action following unsuccessful attempts by the Department to gain compliance.

An exit interview was conducted and a copy of this report will be provided to the facility via email. A copy must be signed and returned to the Department.

NAME OF LICENSING PROGRAM MANAGER: Lauren Crocker
NAME OF LICENSING PROGRAM ANALYST: Sarah Benson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025

LIC809 (FAS) - (06/04)

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