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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803898
Report Date: 03/22/2022
Date Signed: 03/22/2022 11:09:17 AM


Document Has Been Signed on 03/22/2022 11:09 AM - 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:ESPLANA B. ANGELINAFACILITY TYPE:
740
ADDRESS:39 VIA MARCIANATELEPHONE:
(707) 648-7983
CITY:AMERICAN CANYONSTATE: CAZIP CODE:
94503
CAPACITY:6CENSUS: 6DATE:
03/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Care Giver, Elvira Dula
Licensee, Jean Felix		TIME COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Pink Lady Care home, LLC. for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by Care Giver, Elvira Dula and was granted access into the facility. Licensee arrived 45 minutes later.

LPA toured the facility with Care Giver, Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on 11/2021 at the time of the visit. Facility smoke detector was missing in Room #2 (See LIC 809D and picture). During the inspection, LPA found both the front door and the back sliding door were equipped with an auditory device, but was not working during the inspection (See LIC 809D). There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occurs. Hot water temperature measured at 115 degrees, within Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 2 resident’s bathrooms while touring facility. The facility serves residents with dementia and has a plan of operation for special care and programming. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations at the time of the visit. There are special provisions made for individuals with special dietary needs. There was a supply of cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents in the common areas at the facility were supplied with individual paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Residents specific special needs is posted on the fridge in the kitchen area. Food is available for residents any time of the day. Medications were centrally stored in a locked cabinet. Toxins are locked in the laundry room.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE supply stored in the garage. Facility is in the process of being N95 Fit tested. (Report continued on LIC 809C)
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022
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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Document Has Been Signed on 03/22/2022 11:09 AM - 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: 03/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. LPA observed Room #2 without a smoke detector.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above due to missing a smoke detector in Room #2 where a resident resides which poses an immediate health and safety risk to residents in care.
POC Due Date: 03/23/2022
Plan of Correction
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Licensee to submit LIC 9098 and proof that there is a smoke detector in ALL rooms. In addition, Licensee to submit a plan for future compliance.
Type A
Section Cited
CCR
87705(j)
The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 auditory devices were not operable during the inspection which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/23/2022
Plan of Correction
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Licensee to submit an LIC 9098 regarding having the auditory devices operable in both doors. In addition, Licensee to submit a plan for future compliance.

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: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022
LIC809 (FAS) - (06/04)
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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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PINK LADY CAREHOME, LLC.
FACILITY NUMBER: 286803898
VISIT DATE: 03/22/2022
NARRATIVE
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LPA requested the following documents be sent to CCL:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 610E-S Supplemental Emergency Disaster Plan for RCFE
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Administrator Certificate
Copy of Certificate of Liability Insurance
Facility sketch

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 a copy of this report along with appeal rights were given to the licensee.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
LIC809 (FAS) - (06/04)
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