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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803898
Report Date: 04/29/2025
Date Signed: 04/29/2025 04:30:25 PM

Document Has Been Signed on 04/29/2025 04:30 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:PINK LADY CAREHOME, LLC.FACILITY NUMBER:
286803898
ADMINISTRATOR/
DIRECTOR:		MARY GRACE DEFEOFACILITY TYPE:
740
ADDRESS:39 VIA MARCIANATELEPHONE:
(707) 731-2345
CITY:AMERICAN CANYONSTATE: CAZIP CODE:
94503
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
04/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Mary Grace Defeo, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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At approximately 2:00 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and quarterly non-compliance visit and was greeted by facility Staff. Mary Grace Defeo, Administrator was contacted via telephone and arrived at approximately 3:00 PM. Facility is a Residential Care Facility for the Elderly (RCFE) with six (6) residents in care (one was away in the hospital during today's inspection). Facility has a Dementia Care Plan, a Hospice waiver for two (2), and is approved for 4 non-ambulatory residents, two (2) of which may be bedridden. Facility currently has three (3) Hospice residents in care. Administrator will submit a request for a Hospice exception to the Department for the third resident..

Facility is currently on Non-Compliance for the following reasons:
Lack of Liability Insurance in the proper amounts.
Lack of proper funds to properly maintain facility.
LPA will return to RO to conduct further file review and consult with Licensing Program Manager (LPM) regarding the facility's non-compliance status and will follow up with facility at a later date.

At approximately 2:20 PM, LPA initiated a tour of the facility and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperatures in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, and hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations.

Continued on LIC809C...
Bethany MoellersTELEPHONE: (707) 588-5040
Julie FlorioTELEPHONE: (707) 588-5026
DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PINK LADY CAREHOME, LLC.
FACILITY NUMBER: 286803898
VISIT DATE: 04/29/2025
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Continued from LIC809...

LPA observed a fold-up roll away bed in the master bedroom walk-in closet. Staff and Administrator state that it is used for their 24 hour staff who sleep in the living room when on shift. LPA informed Administrator that staff shall not sleep in a common area of the facility or any room not approved on a fire clearance for staff sleeping quarters in order to operate in compliance with regulation.

Cabinets containing cleaning supplies and other items that could pose a risk were observed locked. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There is a shaded seating area in the backyard with outdoor space for activities. LPA inspected one unlocked shed in the backyard which contained care equipment, holiday decorations, and personal items. LPA observed residents in their bedrooms watching TV. Facility has an internet access device designated for resident use and internet access. Facility telephone was tested an operational during inspection.

Facility's fire extinguisher was observed fully charged and was last inspected 02/2025. Smoke and carbon monoxide detectors were tested and operational during inspection.

LPA will return to RO to conduct further file review and consult with LPM. LPA will return at a later date to complete inspection and conduct file review and review medications and medication records. LPA may issue citations at that time. Facility does not handle P&I cash resources for residents.

No deficiencies cited during today's inspection.

Exit interview conducted with Administrator, whose signature on form confirms receipt of documents. Appeal rights provided.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie FlorioTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
LIC809 (FAS) - (06/04)
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