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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525002755
Report Date: 06/09/2021
Date Signed: 06/09/2021 02:37:20 PM

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:LASSEN HOUSE SENIOR LIVINGFACILITY NUMBER:
525002755
ADMINISTRATOR:MATLOCK, ESMERALDAFACILITY TYPE:
740
ADDRESS:705 LUTHER RDTELEPHONE:
(530) 529-2900
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY:86CENSUS: 71DATE:
06/09/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Esmeralda Matlock; AdministratorTIME COMPLETED:
02:45 PM
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On 6/9/21 at 12:45 PM, Licensing Program Analyst (LPA) Cheng conducted an unannounced Health and Safety Case Management visit simultaneously with LPA's complaint visit, complaint #25-AS-20210603155243, and met with Administrator Esmeralda Matlock. Prior to initiating the complaint visit, 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; contacted Administrator 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: N-95 Mask. Additionally, LPA was screened by facility front desk receptionist.

LPA toured the facility inside and out including but not limited to facility kitchen, dining area, outside area, recreation area, bathrooms, memory care, and resident rooms. LPA observed facility to be clean and free of odor. Facility has sufficient COVID posters throughout the facility. All sink stations had proper hand washing signs. All staff members were wearing a surgical mask and facility had multiple hand sanitizing stations throughout the facility. Facility has a 7-day non-perishable and 2-day perishable supply of food. Facility's smoke and carbon monoxide detectors were observed as operational.

Facility had 3 staff working in the Assisted Living portion, 3 staff working in Memory Care Unit, and 2 staff working in the kitchen.

No deficiencies observed.

Exit interview conducted and a copy of report was given.
SUPERVISOR'S NAME: Kevin MknellyTELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
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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