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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700811
Report Date: 06/30/2022
Date Signed: 06/30/2022 11:44:29 AM

Document Has Been Signed on 06/30/2022 11:44 AM - 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:TREE OF LIFEFACILITY NUMBER:
342700811
ADMINISTRATOR:CUSTURA, MARIAFACILITY TYPE:
740
ADDRESS:6924 LAUREL OAK WAYTELEPHONE:
(916) 595-5738
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 6CENSUS: 5DATE:
06/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Maria CusturaTIME COMPLETED:
11:50 AM
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On 6/30/2022, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a required annual. LPA met with Caregiver, Hope Smith, who contacted Administrator, Maria Custura, who arrived shortly to the facility. LPA explained purpose of inspection to Administrator. Before today's inspection, LPA completed required COVID-19 testing protocols and completed daily assessment and confirmed the facility does not currently have any positive Covid-19 diagnoses. LPA was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. The facility is licensed for (6) residents and has a hospice waiver for (4). There are (5) residents in the facility and no resident on hospice.

LPA and Administrator toured the interior and exterior of the facility and there were no safety risk or personal rights violation. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. LPA observed hand washing signs, paper towels and soap present in the restrooms. LPA advised Administrator that all trash can should have lids. LPA observed the Ombudsman and CCLD poster at entrance of the facility. Fire extinguishers last serviced 6/17/2022. LPA observed the facility to have good documentation of staff and residents daily temperature screening. LPA and Administrator followed the infection control domain guidelines and facility was found to be in substantial compliance at this time. LPA observed all staff to be wearing surgical masks. PPE supplies are sufficient as well as Covid testing supplies.

LPA reviewed the Administrator Certificate (#6053006740 exp 7/25/2023) and Liability Insurance to be up to date. There were no deficiencies observed during today's inspection.

Exit interview. Copy of report left at facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2022
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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