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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455001891
Report Date: 03/21/2023
Date Signed: 03/21/2023 12:34:36 PM


Document Has Been Signed on 03/21/2023 12:34 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



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:
03/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Rhonda JohnsonTIME COMPLETED:
12:45 PM
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LPA Hiratsuka, conducted this unannounced annual visit. LPA wore a surgical mask and observed staff wearing them. Sophia Johnson and Christian Fisher arrived at the facility and completed the visit along with Administrator Rhonda Johnson.

This facility has five resident rooms; one shared and four private. There are two common bathrooms and one private bathroom. The dining and kitchen area is separate from the sitting area. There is a detached two car garage.

Multiple topics were discussed.

No deficiencies cited.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2023
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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