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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525002755
Report Date: 04/12/2022
Date Signed: 04/12/2022 01:29:18 PM


Document Has Been Signed on 04/12/2022 01:29 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
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: 67DATE:
04/12/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Sue Todd - executive directorTIME COMPLETED:
02:00 PM
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04/12/2022 12:45 PM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with Executive Director Sue Todd. The purpose of this visit was to conduct a case management investigation. Prior to initiating the 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: N95 Mask, gloves. LPA was screened by Sue Todd.

Today's meeting concerns an investigation into an incident report that was received from the facility on 04/05/2022 regarding an incident that occurred at the facility on 03/31/2022. It was reported that on 3/31/2022 Resident 1 (R1) was brought back to the facility by the local police department at 8:30 pm. The police officer reported that R1 was found 2 blocks away from the facility, R1 told the officer that they thought they were walking their dog to the church but took a wrong turn. Upon their return to the facility it was discovered that R1’s blood sugar was low and R1 was very weak and tired. R1 was given a sandwich and juice and was monitored for the rest of the evening. As a result of this incident R1 was given an order for a wanderguard which was placed on R1. R1 was placed on checks every 2 hours for safety. R1’s physician adjusted R1’s diabetic medications and a new diet order was placed.

Continued on LIC809-C

SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022
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: 04/12/2022
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LPA’s review of incident report from Red Bluff Police Department stated R1 was found with his dog and appeared lost. R1 told officers they did not know where they lived but thought it was just down the street. R1’s LIC602 Physician’s Report states that R1 is allowed to leave the facility unassisted with an explanation that family are to drive R1. This does not apply to R1 taking their dog for a walk for wich her does not normally require assistance. Review of R1’s LIC602 dated 10/20/2021 revealed that R1 has a primary diagnosis of cognitive decline (mild cognitive impairment) and Diabetes Type 2 for which R1 takes medication. R1 is unable to manage their own medication. Review of R1’s Pre-placement/Appraisal Plan showed that a simple pleasure R1 enjoys is R1’s dog. Cognitive Function is “Modified Independence” which means R1 experiences some confusion, forgetfulness, and requires daily or weekly reminders.

LPA conducted interviews with facility staff and learned that R1 has never done this before, R1 walks their dog 4-5 times per day. When R1 went for a walk that evening they checked out with the med tech a little before 7:00 PM and was brought back by police and R1’s family to the facility a little before 8:00 PM. When police picked up R1 they brought him to his family’s local home and the family accompanied R1 back to the facility. It was learned that R1 has a glucose monitor in their room and the med tech monitors R1 while R1 checks their glucose levels, the med tech then documents the twice daily glucose check in the MAR. Additionally R1 was prescribed a wander guard which he is currently wearing.

No deficiencies cited. Exit interview conducted and a copy of the report was emailed to Sue Todd.

SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
LIC809 (FAS) - (06/04)
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