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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004307
Report Date: 10/08/2021
Date Signed: 10/08/2021 04:32:14 PM

Document Has Been Signed on 10/08/2021 04:32 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:PINE HOLLOW CARE HOMEFACILITY NUMBER:
347004307
ADMINISTRATOR:MATSKEVICH, TATYANAFACILITY TYPE:
740
ADDRESS:8515 RAPOZO CT.TELEPHONE:
(916) 628-6150
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 6CENSUS: 4DATE:
10/08/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Tatyana Matskevich, AdministratorTIME COMPLETED:
04:45 PM
NARRATIVE
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LPA Williams arrived on Friday, October 8, 2021 to open a separate complaint investigation. Prior to the visit, 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 he applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

LPA was screened at front door. LPA met with Tatyana Matskevich, Administrator, and requested an Appraisal/Needs and Services Plan, amongst other things. The facility does not have an Appraisal/Needs and Services Plan.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Jacob Williams
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2021
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 10/08/2021 04:32 PM - It Cannot Be Edited


Created By: Jacob Williams On 10/08/2021 at 03:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: PINE HOLLOW CARE HOME
FACILITY NUMBER: 347004307

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/15/2021
Section Cited
CCR
874579(c)(1)

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87457(c)Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs (1)The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors.
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Administrator to fill out resident's Needs and Service Plan (LIC625) or similar form, maintain it in resdient's file, and email a copy to Licensing by POC date.
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Facility has not filled out a Needs and Services plan (LIC625) for resident which poses an immediate health and safety concern for the resident
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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:Anthony Perez
LICENSING EVALUATOR NAME:Jacob Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2021


LIC809 (FAS) - (06/04)
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