525002755-2-23-2021-25-AS-RLBN-BYPVAL-20210301151606

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 525002755
Report Date: 02/23/2021
Date Signed: 02/23/2021 01:22:11 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/04/2020 and conducted by Evaluator Donna Gurriere

COMPLAINT CONTROL NUMBER: 25-AS-20201204092836

FACILITY NAME:	LASSEN HOUSE SENIOR LIVING		FACILITY NUMBER:	525002755
ADMINISTRATOR:	MATLOCK, ESMERALDA		FACILITY TYPE:	740
ADDRESS:	705 LUTHER RD		TELEPHONE:	(530) 529-2900
CITY:	RED BLUFF	STATE: CA	ZIP CODE:	96080
CAPACITY:	86	CENSUS: 54	DATE:	02/23/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	ESMERALDA MATLOCK		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Emergency exit is blocked by chairs and artificial plants.
Residents observed not social distancing or wearing masks in the common area.

INVESTIGATION FINDINGS:

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Donna Gurriere, Licensing Program Analyst (LPA) was in contact with Esmeralda Matlock, Administrator. A physical visit could not be made due to the orders in place regarding the Covid Virus. It was alleged that An emergency exit is blocked by chairs and artificial plants and Residents were observed not wearing a mask and not social distancing in the common area.

An emergency exit is blocked by chairs and artificial plants. During the investigation, documents and photos were received and reviewed. Documents included the facility’s Emergency and Disaster Plan and the photos showed that there was not a blockage in front of the exit doors. The administrator, five staff persons and a resident were interviewed. It was reported that a new resident moved into the facility and had her chairs and a plant temporarily placed by the exit door; however, it was stated by all staff persons that the exit was not blocked by the chairs or plants. On 12/14/20, LPA Knight conducted a virtual walk through of the facility to see if chairs and plants were blocking the emergency exit. LPA Knight indicated in her report that she did not see chairs and plants blocking an exit door.

**continued**

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20201204092836

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: LASSEN HOUSE SENIOR LIVING	FACILITY NUMBER: 525002755
	VISIT DATE: 02/23/2021

NARRATIVE

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***continued***

Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated.

Residents observed not social distancing or wearing masks in the common area. During the investigation, documents were received and reviewed. Documents included the corporation’s Novel Coronavirus Illness and Outbreak Policy and Procedure. The administrator, five staff persons and a resident were interviewed. It was reported that at times residents with dementia will attempt to come into the common area without a mask; however, it was stated by several staff persons that they are “quick” to ensure that the resident is wearing their mask and that they are six feet apart. It was further reported that currently, activities are done individually or in the hallway of the facility and that for the most part residents are not congregating in the common area. On 12/14/20, LPA Knight conducted a virtual walk through of the facility and did not observe residents without masks or not social distancing.

Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated.

Deficiencies were not cited for the above mentioned allegations.

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2021

LIC9099 (FAS) - (06/04)

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