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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525002755
Report Date: 10/10/2023
Date Signed: 10/10/2023 01:43:51 PM


Document Has Been Signed on 10/10/2023 01:43 PM - 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:
10/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Sue Todd - administratorTIME COMPLETED:
01:50 PM
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10/10/ 2023 1:00 PM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with administrator Sue Todd. Today’s visit is regarding an incident that occurred on 10/08/2023 and was reported to licensing on 10/10/2023.

It was reported that on 10/08/2023 at 5:24 PM Resident 1 (R1) was getting up from a table in the dining room and they lost their balance, fell backwards and hit the back of their head on a table. R1 did not lose consciousness and was awake and responding. R1 sustained a laceration to their right elbow. R1 was transported to ER for evaluation and subsequently admitted for acute hyponatremia, acute ground level fall with head strike and elbow contusion.

During the course of the investigation, it was learned that R1 was hospitalized for low sodium level, not related to R1’s head strike. R1 is currently still at the hospital where they are working on getting R1’s sodium regulated.

In order to prevent this from happening again the facility has requested home health to come in to ensure R1 has no further issues. Facility is going to request physical therapy for R1 due to a recent issue with getting up and down from a seated position.

No deficiencies were 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: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023
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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