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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803898
Report Date: 05/06/2024
Date Signed: 05/06/2024 12:54:40 PM


Document Has Been Signed on 05/06/2024 12:54 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:PINK LADY CAREHOME, LLC.FACILITY NUMBER:
286803898
ADMINISTRATOR:MARIA BUIFACILITY TYPE:
740
ADDRESS:39 VIA MARCIANATELEPHONE:
(707) 731-1842
CITY:AMERICAN CANYONSTATE: CAZIP CODE:
94503
CAPACITY:6CENSUS: 4DATE:
05/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jean FelixTIME COMPLETED:
01:10 PM
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At approximately 9:00AM. Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a Required-1 Year inspection. LPA met with Care Provider Princess Villanueva and explained the purpose of the visit. Administrator was not present during this inspection. Administrator certificate for Maria Bui is current. LPA was informed the Licensee was away from the facility purchasing groceries. LPA toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. Staff and resident files were reviewed. First Aid/CPR certification was current. Medications were also reviewed. The common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. The bathrooms were clean and in good repair. The kitchen was clean and in good repair. Cooking/dining equipment and utensils were present. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Medication is locked and not accessible. The facility was observed to be at a comfortable temperature. First aid kit fully stocked and ready for emergency use. Fire extinguishers were fully charged. Smoke detectors are all operational. Carbon Monoxide Detector was present. All employees requiring background checks are cleared. No pools/bodies of water are on the premises. Staff was not able to provide LPA documentation of the last disaster/emergency drill. Licensee arrived at 12:15PM and provided LPA with documentation of a completed drill.

LPA requested the following documents during this visit:

Evidence of Liability Insurance

LIC308, Designation of Responsibility

LIC500, Personnel Summary



No deficiencies were observed in the areas inspected, No citations were issued during today’s visit.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2024
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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