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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455001891
Report Date: 03/16/2022
Date Signed: 03/16/2022 04:17:32 PM


Document Has Been Signed on 03/16/2022 04:17 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:LIFE PASTICHEFACILITY NUMBER:
455001891
ADMINISTRATOR:JOHNSON, RHONDAFACILITY TYPE:
740
ADDRESS:19323 HOLLOW LANETELEPHONE:
(530) 215-1685
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:6CENSUS: 4DATE:
03/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Joann Jetton, CaregiverTIME COMPLETED:
04:30 PM
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On 03/16/2022 Licensing Program Analyst (LPA) Misty Valencia arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Joann Jetton, Caregiver and explained the purpose of the visit. The administrator was not available for the visit. Prior to initiating the annual inspection, 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. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical masks. Additionally, LPA was screened by care staff at the front door before entering facility. .

LPA Valencia and Ms. Jetton toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, bathrooms, kitchen, storage areas and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Ms. Jetton completed the infection control domain and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report was emailed to administrator Rhonda Johnson.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022
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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