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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525002755
Report Date: 06/06/2024
Date Signed: 06/06/2024 02:37:46 PM


Document Has Been Signed on 06/06/2024 02:37 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:BRASWELL, NICOLEFACILITY TYPE:
740
ADDRESS:705 LUTHER RDTELEPHONE:
(530) 529-2900
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY:86CENSUS: 57DATE:
06/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Nicole Braswell - administratorTIME COMPLETED:
02:45 PM
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06/06/2024 12:15 PM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with administrator Nicole Braswell and explained the purpose of the visit.


LPA Knight and the administrator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas, activity rooms, yards, and dining room. Staff and resident files were reviewed. All employees requiring background checks are cleared.

Common area was clean and in good repair. 9 of 10 bedrooms that were inspected had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Medication is locked in the medication room. All required postings are displayed within facility.

Fire extinguishers fully charged and inspected. Johnson Controls conducted 20 year inspection and UL testing on sprinkler system in November 2023. Red Bluff Fire Department inspected the fire sprinkler system and smoke detectors on April 23, 2024.

There are no pools/bodies of water are on premises. Last disaster drill was conducted in May 2024 which was a fire drill. Facility full evacuation drill scheduled for June 2024 with the local fire department. The facility has been conducting fire drills every month.

A deficiency is being being cited as a result of today’s inspection and is included on the attached LIC8-9-D. LPA observed that 1 of 10 resident rooms does not have a bed, but does have a recliner that the resident prefers to sleep in. LPA has suggested that the facility request an exception specific to this resident's choice to sleep in a recliner.

Exit interview conducted and copy of report was provided to administrator Nicole Braswell.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024
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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Document Has Been Signed on 06/06/2024 02:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 525002755

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(3)(a)

87307 Personal Accommodations and Services (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (A) A bed for each resident, except that married couples may be provided with one appropriate sized bed. Each bed shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation the licensee did not comply with the section cited above in 1 of 10 resident rooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2024
Plan of Correction
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Licensee agrees to either place a bed in the resident room or obtain an exception from the department approving the use of a recliner for sleeping specific to this resident only.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024
LIC809 (FAS) - (06/04)
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