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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455001891
Report Date: 04/21/2022
Date Signed: 04/22/2022 07:30:51 AM


Document Has Been Signed on 04/22/2022 07:30 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:LIFE PASTICHEFACILITY NUMBER:
455001891
ADMINISTRATOR:JOHNSON, RHONDAFACILITY TYPE:
740
ADDRESS:19323 HOLLOW LANETELEPHONE:
5302151685
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:6CENSUS: 4DATE:
04/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Joann Jetton, Direct Care StaffTIME COMPLETED:
01:50 PM
NARRATIVE
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On 4/21/22 at 10:45 a.m., Dawn Keane, Licensing Program Analyst (LPA) and Jacqueline Juarez, Audit Manager (AM) arrived at the facility unannounced to conduct a case management visit to copy facility files for an ongoing investigation. LPA Keane met with care giver Care Giver (CG), Joann Jetton who was not wearing a mask. LPA informed CG that masks are required for all staff at this time. LPA informed CG that when LPA last visited, staff was not wearing masks. Technical advice has been given twice to facility for not wearing masks as required.

LPA Keane 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 was contacted to complete a facility risk assessment, but the phone's voice mail was full LPA Keane and AM ensured that hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA Keane was screened at the front door by staff.
During today’s inspection, the Administrator was not available to come to the facility. It has been noted during other on site inspections that the Administrator is not present and/or available. LPM L. Munoz contacted the Administrator today, 4/21/22, who stated her daughter is the designated substitute however is also not available. At this time, the facility does not have a designated substitute Administrator as required.
The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.


An exit interview was conducted, and a copy of the report was given to CG.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Dawn KeaneTELEPHONE: (530) 895-2660
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022
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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Document Has Been Signed on 04/22/2022 07:30 AM - It Cannot Be Edited

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: LIFE PASTICHE
FACILITY NUMBER: 455001891

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/21/2022
Section Cited

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87405(a) (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient
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number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications .......
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Dawn KeaneTELEPHONE: (530) 895-2660
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022
LIC809 (FAS) - (06/04)
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