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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002615
Report Date: 08/09/2022
Date Signed: 08/09/2022 11:30:00 AM


Document Has Been Signed on 08/09/2022 11:30 AM - It Cannot Be Edited

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: 24DATE:
08/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jennifer Boss, AdministratorTIME COMPLETED:
11:45 AM
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08/09/2022 10:00 am Licensing Program Analysts (LPAs) Misty Valencia and Shannon Diegoruelas, arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Jennifer Boss, Administrator (Admin) and explained the purpose of the visit. Prior to initiating the annual inspection, 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 contacted AD and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical mask. Additionally, LPAs were screened by Administrator assistant.

LPAs and the Admin toured facility to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, three (3) bathrooms, two (2) resident rooms, kitchen, storage areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPAs and the Admin completed the infection control domain and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of report was emailed to Admin.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022
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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