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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002764
Report Date: 08/22/2022
Date Signed: 08/22/2022 10:48:53 AM


Document Has Been Signed on 08/22/2022 10:48 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:SAINT LORENZ ASSISTED LIVINGFACILITY NUMBER:
455002764
ADMINISTRATOR:BIRD, JAMESFACILITY TYPE:
740
ADDRESS:740 LAKE BLVDTELEPHONE:
(650) 632-5300
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:17CENSUS: 15DATE:
08/22/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:DEBBIE BIRDTIME COMPLETED:
11:00 AM
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Donna Gurriere, Licensing Program Analyst was in contact and met with Debbie Bird, RN.


LPA Gurriere completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID 19 infection to affirm no COVID-19 related symptoms. The administrator/staff person was contacted to complete a facility risk assessment. LPA Gurriere ensured that hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. Additionally, LPA Gurriere was screened by a staff person upon entering the facility.

The purpose of the visit is to conduct a case management visit to follow up on an incident whereas a resident fell when he was exiting from the bus. Resident hit his head and had a laceration with a small cut. It was reported that the wound was kept clean and dry and that resident is doing well.

Exit interview with no deficiencies cited.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2022
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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