<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002615
Report Date: 08/28/2024
Date Signed: 08/28/2024 09:51:57 AM

Document Has Been Signed on 08/28/2024 09:51 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:LAVENDER HILLS ASSISTED LIVING IIIFACILITY NUMBER:
455002615
ADMINISTRATOR/
DIRECTOR:		BOSS, JENNIFER BFACILITY TYPE:
740
ADDRESS:1794 COLLYER DRIVETELEPHONE:
(530) 245-9970
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY: 29CENSUS: 24DATE:
08/28/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Assistant Administrator, Naitasha Peerman
Administrator, Jennifer Boss		TIME VISIT/
INSPECTION COMPLETED:
10:00 AM
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
On August 28, 2024 at approximately 08:30 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Lavender Hills Assisted Living III for the purpose of conducting a Case Management-Annual Continuation. LPA was greeted at the door by Assistant Administrator, Naitasha Peerman, and was granted access into the facility. Administrator arrived one hour later.

LPA and Assistant Administrator toured the facility and observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Water temperature in residents bathrooms measured at 109 degrees, within acceptable range of 105 to 120 degrees F. LPA observed sufficient perishable and non-perishable foods located in the kitchen. 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 an occupied residents bedroom and a vacant bedroom were conducted, and bedrooms inspected have lighting and appropriate furnishing. First Aid kit was inspected and found to be appropriate during the inspection. LPA reviewed the Infection Control Plan and the Emergency Disaster Plan with the Assistant Administrator. Emergency Disaster Drill was last conducted on July 2024.

No deficiencies were observed or cited during today's Case Management-Annual Continuation. Exit interview was conducted and a copy of this report was signed and given to Administrative Staff.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1