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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803898
Report Date: 08/19/2024
Date Signed: 08/19/2024 12:49:11 PM


Document Has Been Signed on 08/19/2024 12:49 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: 0DATE:
08/19/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:43 AM
MET WITH:Jean Felix, LicenseeTIME COMPLETED:
12:29 PM
NARRATIVE
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A NonCompliance conference meeting was conducted today in the Santa Rosa Regional Office. Present in the meeting were Acting Regional Manager, Bethany Moellers, Licensing Program Manager, Kimberley Mota, Licensing Program Analyst Araceli Canela, and Licensee, Jean Felix.

The purpose of the Non-Compliance conference was to discuss areas of non-compliance and results from the facilities financial Audit that was recently conducted. Community Care Licensing concerns regarding the licensee not having adequate financial plan required by section 87213 finances to ensure sufficient income resources generated to cover its operating expenses of the operation of Pink Lady Care Home LLC 286803898.

Licensee to acquire liability insurance with adequate coverage to be in compliance of Health and Safety Code, Section 1569.605. and provide proof by September 2, 2024.

Licensee to be on quarterly financial monitoring for a period of six months or until it is evident that the licensee has an adequate financial plan in place. The first due date being 10/1/2024 for (July, August and September 2024 monitoring period). Financial monitoring documents to submit for review to include utility bills, bank statements - all pages for all accounts the facility uses; LIC401 and LIC403.

Facility to submit current lease agreement and provide copy to LPA Canela.


Continue report see LIC809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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
VISIT DATE: 08/19/2024
NARRATIVE
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The licensee was provided copies of the following regulations:

• Title 22, Regulation 87405 – Administrator Qualifications and Duties.
• Title 22, Regulation 87205, Accountability of Licensee
• Title 22, Regulation 87213 - Finance; Record
• Health and Safety Code, Section 1569.605.


The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/19/2024 12:49 PM - 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: PINK LADY CAREHOME, LLC.
FACILITY NUMBER: 286803898

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/02/2024
Section Cited
HSC
1569.605

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Liability On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees
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Facility agrees to submit proof of liability insurance in the correct liability amounts to LPA Canela by Plan of correction date 9/2/2024
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This requirement was not met as evidenced by: Based review of facilities current liability insurance today and on 5/8/2024. Facility had proof of liability insurance but it did not meet the liability required amount per regulation requirement. This poses a potential risk to the Health & Safety of residents in care.
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Type B
09/18/2024
Section Cited
CCR87213

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Finances-87213 The licensee shall have a financial plan that conforms to the requirements of Section 87155, Application for License, and that assures sufficient resources to meet operating costs for care of residents; shall maintain adequate financial records; and shall submit such financial reports as may be required upon the written request of the licensing agency. Such request shall explain the need for disclosure. The licensing agency reserves the right to reject any financial report and to request additional information or examination including interim financial statements.
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Licensee to send in written statement they will submit quarterly financial records as requested by the department.


Plan of correction due 9/18/2024
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This requirement was not met as evidenced by:Based on FInancial Audit conducted by the department, Licensee failed to have an adequate financial plan. This poses a potential risk to the Health & Safety of residents in care.
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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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 08/19/2024 12:49 PM - 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: PINK LADY CAREHOME, LLC.
FACILITY NUMBER: 286803898

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/18/2024
Section Cited
CCR
87405(b)(c)(d)

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Administrator - Qualifications and Dutie (b) The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee.
(c) Failure to comply with all licensing requirements pertaining to certified administrators may constitute cause for revocation of the license of the facility.
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
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Facility to submit written plan on how they will be in compliance with regulation 87405 and provide requested documents to Community Care Licensing as requested.

POC due date 9/18/2024
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This requirement was not met as evidenced by:Based on FInancial Audit conducted by the department, Licensee failed to properly operate the facility financially. This poses a potential risk to the Health & Safety of residents in care.
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Type B
09/18/2024
Section Cited
CCR87205(a)

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Accountability of Licensee Governing Body (a) The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves.
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Facility to submit written plan on how they will be in compliance with regulation 87205(a)

POC due date 9/18/2024
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This requirement was not met as evidenced by : Based on FInancial Audit conducted by the department, Licensee failed to operate the facilities financial matters. This poses a potential risk to the Health & Safety of residents in care.
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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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4