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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002615
Report Date: 07/21/2021
Date Signed: 07/21/2021 12:12:49 PM

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 IIIFACILITY NUMBER:
455002615
ADMINISTRATOR:BOSS, JENNIFER BFACILITY TYPE:
740
ADDRESS:1794 COLLYER DRIVETELEPHONE:
(530) 245-9970
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:29CENSUS: 22DATE:
07/21/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Jennifer Boss and Sabrina StrongTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) K. Hiratsuka, arrived at the facility unannounced on 07/21/2021 to conduct a case management visit. LPA met with Administrators Jennifer Boss and Sabrina Strong, and explained the purpose of the visit. Prior to initiating the visit, 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 ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by the Sara Bennett..

LPA conducted this visit in response to an incident reported by the facility yesterday. LPA interviewed the caregiver involved and Co-Administrators Jennifer Boss and Sabrina Strong. LPA also obtained some more information from the former resident's file.

The situation is going to be further investigated

No deficiencies cited.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
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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