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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700429
Report Date: 02/23/2023
Date Signed: 02/23/2023 12:13:41 PM


Document Has Been Signed on 02/23/2023 12:13 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:NEW LIFEFACILITY NUMBER:
342700429
ADMINISTRATOR:CUSTURA, VLADFACILITY TYPE:
740
ADDRESS:6307 GRANT AVETELEPHONE:
(916) 285-5302
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
02/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Vlad CusturaTIME COMPLETED:
12:30 PM
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On 2/23/2023, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct an annual inspection. LPA met with Administrator, Vlad Custura, and explained the purpose of the visit. Prior to entering the facility, LPA ensure to apply hand sanitizer and wore a surgical mask.

The facility has a capacity of 6, today's census is 6. The facility is in compliance to the the hospice waiver of (4) as LPA observed the facility to have (3) residents on hospice services.

LPA and Administrator toured the interior of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: (6) residents bedroom, (3) bathroom, laundry room, kitchen, private staff room and common areas. LPA observed the medication to be locked and secured in the private staff room. LPA observed (4) residents to be in their private bedrooms and (2) residents to be watching television in the common area.

LPA observed the Administrator Certificate to be up to date with expiration date of 4/30/2024. LPA observed the facility to have their liability to be renewed.

LPA requested a copy of the liability insurance, Administrator Certificate, and LIC 500 to be emailed to LPA by Friday March 3, 2023.

Infection Control Domain was completed with Administrator, the facility is found to be in compliance. No deficiencies observed.

Exit interview conducted and a copy of the report was left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2023
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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