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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525002755
Report Date: 09/14/2021
Date Signed: 09/14/2021 11:36:48 AM

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:TODD, SUSANFACILITY TYPE:
740
ADDRESS:705 LUTHER RDTELEPHONE:
(530) 529-2900
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY:86CENSUS: 61DATE:
09/14/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:SUSAN TODDTIME COMPLETED:
11:45 AM
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Donna Gurriere, Licensing Program Analyst (LPA) arrived at the facility unannounced to conduct a case management visit regarding an incident. Met with Susan Todd, Administrator.

LPA Gurriere completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID 19 infection to affirm no COVID-19 related symptoms. The administrator/staff person was contacted to complete a facility risk assessment. LPA Gurriere ensured that hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by administrator upon entering the facility.

It was reported that on 05/14/21 a resident (Resident 1) exited through a bedroom window by unscrewing the alarm and pushing out the screen. Law enforcement was contacted and they along with staff searched for the resident. The resident was located at a nearby building next to the facility. The resident was escorted back to the facility without incident. The resident's Physician Report indicates that the resident cannot leave the facility without assistance. The resident was placed on two hour checks and the screen was replaced. Resident has not had any other incidents and is still on two hour checks. Resident is doing well.

continued
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/14/2021
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A second incident occurred on 05/25/21 and it was reported that a resident (Resident 2) was found on the floor in his bedroom and that his faucet was on full force, which caused his bedroom and bathroom to be flooded. It was reported that the resident suffered a head injury and required sutures to the left temple of his head. Currently, the resident is healed from the head injury and is doing well.

An exit interview was conducted, and a copy of the report was given to the administrator. No deficiencies cited.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
LIC809 (FAS) - (06/04)
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