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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803898
Report Date: 08/13/2020
Date Signed: 08/13/2020 03:06:41 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:PINK LADY CAREHOME, LLC.FACILITY NUMBER:
286803898
ADMINISTRATOR:ESPLANA B. ANGELINAFACILITY TYPE:
740
ADDRESS:39 VIA MARCIANATELEPHONE:
(707) 648-7983
CITY:AMERICAN CANYONSTATE: CAZIP CODE:
94503
CAPACITY:6CENSUS: 4DATE:
08/13/2020
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Angie Esplana/Diana HalstromTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Angela Elliott conducted a tele-visit inspection on 8/13/2020 at approximately 2:40 PM to conduct a post licensing visit. LPA is conducting a tele-visit with Diana Halstrom, staff and Angie Esplana, Administrator. LPA obtained email address to send LIC 809 and requested staff sign copy and emailed back to LPA before 8/14/2020. The inspection is being conducted by tele-inspection due to COVID-19. The reader is advised that the LPA did not physically make a site visit. Currently there are 4 residents in care.

The amount of fresh and nonperishable foods appeared to be within regulation. Medications were observed locked in cupboards. Toxins were observed locked in a cabinet in the laundry area. Bathrooms were equipped with necessary grab bars and non-slip floors/mats and appeared to have sufficient hygiene products. LPA observed that resident rooms were furnished per regulations. Fire extinguishers were last inspected 8/12/2020 and Carbon Monoxide Detectors were observed.

LPA observed required postings regarding COVID-19 precautions throughout the facility and required visitation postings. Facility is screening essential visitors at the front door.

LPA observed a sufficient supply of PPE equipment. The facility staff was observed wearing masks during the virtual tour of main entrance, doors, common areas, dining room and kitchen area. LPA reviewed documents in 2 resident files. LPA reviewed 2 staff records and found that staff had current First Aid / CPR training. Administrator stated there are no residents with prohibited conditions at this time. Administrator stated disaster drills are conducted quarterly. Licensee will ensure resident and staff files are current. Licensee will provide annual staff training information for caregivers to LPA. Administrator Angie Esplana Certificate 6025327740 expires 5/26/2021.
Signature on file. No deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2020
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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