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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525002755
Report Date: 08/23/2023
Date Signed: 08/23/2023 11:50:03 AM


Document Has Been Signed on 08/23/2023 11:50 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:LASSEN HOUSE SENIOR LIVINGFACILITY NUMBER:
525002755
ADMINISTRATOR:TODD, SUSANFACILITY TYPE:
740
ADDRESS:705 LUTHER RDTELEPHONE:
(530) 529-2900
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY:86CENSUS: DATE:
08/23/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Sue Tod - administratorTIME COMPLETED:
12:00 PM
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
08/23/2023 11:20 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with Executive Director Sue Todd and Wellness Director Nicole Braswell. The purpose of this visit was to conduct a case management investigation.

Today's meeting concerns an investigation into a non-hospice death report that was received from the facility on 08/18/2023 regarding an incident that occurred at the facility on 08/17/2023. It was reported that on 08/17/2023 staff found Resident 1 (R1) unresponsive when checking on R1 after assisting R1 to bed. Once staff found R1 unresponsive EMS, local police, and administrator were called .

R1 had been observed to be at baseline mentation and condition at breakfast, lunch, and dinner and had attended activities the same day.

Administrator stated R1 has lived in the facility’s memory care since 2016 R1 was in gradual decline but was still ambulatory, still fed themselves but was starting to need more help. R1 still participated in activities. R1 had a particularly good day, was tired before dinner, sat in the living room after dinner for a while after dinner. Staff said he was not in distress or pain, he just put his head on the pillow and passed away.

No deficiencies are being cited as a result of today’s visit.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023
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