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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002615
Report Date: 08/05/2024
Date Signed: 08/05/2024 03:25:18 PM


Document Has Been Signed on 08/05/2024 03:25 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 IIIFACILITY NUMBER:
455002615
ADMINISTRATOR:BOSS, JENNIFER BFACILITY TYPE:
740
ADDRESS:1794 COLLYER DRIVETELEPHONE:
(530) 245-9970
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:29CENSUS: 25DATE:
08/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator, Jennifer BossTIME COMPLETED:
03:30 PM
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On August 5, 2024 at approximately 01:30 PM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Lavender Hills Assisted Living III for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by Administrator, Jennifer Boss and was granted access into the facility.

LPA and the Administrator toured the facility. LPA observed the facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguishers were found to be last charged on February 2024 at the time of the inspection. All smoke detectors and carbon monoxide detectors sound directly to the local fire jurisdiction. LPA reviewed the Fire Inspection Report from Redding County Fire Department to confirm that the carbon monoxide detectors and the smoke detectors have been tested. Water temperature in residents bathrooms measured at 108 degrees, within acceptable range of 105 to 120 degrees F. LPA observed sufficient perishable and non-perishable foods located in the kitchen and outdoor freezer in the back was appropriately stocked. There are special provisions made for individuals with special dietary needs. Food menu was presently available for viewing during the inspection. Medications were centrally stored and locked. Cleaning products and other toxins are located in the laundry room that was locked and inaccessible to residents in care. There was a supply of linens, cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents in the common areas at the facility were supplied with individual paper towels and hand soap. Bathrooms in resident’s rooms have a towel and soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A tour of all residents bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing. LPA reviewed 5 resident files and found those to be appropriate during the review. LPA reviewed 5 staff files and found those to be appropriate during the review. Staff that provide Care and Supervision have valid First Aid/CPR. Emergency Disaster Plan and Infection Control Plan will be reviewed at a later date and time.

Case Management-Annual Continuation will be conducted at a later date and time. No deficiencies were observed or cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was emailed to the Administrator due to printer issues.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 202-0832
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: (916) 307-0474
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2024
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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