<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803898
Report Date: 05/17/2021
Date Signed: 05/17/2021 10:36:50 AM

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: 5DATE:
05/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jean FelixTIME COMPLETED:
11:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Angela Elliott conducted an unannounced Annual Required – 1 year Infection Control inspection to this facility and met with staff Diana Halstrom. Jean Felix, Licensee arrived later. Two residents were observed in the living room and kitchen table eating breakfast. Other residents were resting in their rooms.

LPA arrived at the facility and had temperature checked. Visitor- log in document could not be produced. Licensee showed LPA previous visitor logs forms that had accidentally been discontinued. Licensee indicated visitor log will be reinstated. During facility tour the facility was found to be clean and at a comfortable temperature with all exits free from obstruction. There was one entry point for the facility. Facility has submitted a mitigation program plan that has been approved. Postings pertaining to COVID-19 were throughout the facility. Entrance has a small table with hand sanitizer and other items designated for visitors and staff before coming into work. Licensee indicated there were barriers to getting staff COVID testing and will research further. Facility has PPE supply stored in a cabinet in the hallway. Supplies were not 30 days worth. Licensee indicated shipment was coming in next week. LPA discussed PPE supplies could also be picked up at CCL Regional Office. Client emergency contact information has been updated and Emergency Personnel numbers are posted at the facility. Clients’ medications are stored and locked in a cabinet in the hallway. Facility has a 30-day supply of medication for clients.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2021
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