286803898-5-23-2023-21-AS-FSAI-CS4TUC-20230523150207

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286803898
Report Date: 05/23/2023
Date Signed: 05/23/2023 03:02:15 PM

Document Has Been Signed on 05/23/2023 03:02 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:	ESPLANA B. ANGELINA		FACILITY TYPE:	740
ADDRESS:	39 VIA MARCIANA		TELEPHONE:	(707) 648-7983
CITY:	AMERICAN CANYON	STATE: CA	ZIP CODE:	94503
CAPACITY:	6	CENSUS: 5	DATE:	05/23/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Licensee, Jean Felix Care Giver, Maria Sebastian		TIME COMPLETED:	03:15 PM

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), 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, Maria Sebastian and was granted access into the facility. During a review of the Guardian Background Clearance Roster, LPA observed that 1 out of 3 staff members did not have a Background Clearance (See LIC 809D & Civil Penalty). Licensee arrived 15 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. However, LPA and Caregiver observed the laundry room unlocked and toxins were left accessible to residents in care (See LIC 809D and LIC 812-Observation/Photos). Fire Extinguisher was found to be last charged on December 2022 at the time of the visit. Smoke Detectors and Carbon Monoxide Detectors now sound directly to the Fire Department. 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 108 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 inspection. However, during a tour of the facility with the Caregiver, LPA observed the kitchen sink being clogged, inoperable and covered (See LIC 809D and LIC 812-Observation/Photos) 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. Medications were centrally stored in a locked cabinet. (Report continued on LIC 809C)

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

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 5

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: 05/23/2023

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
26
27
28
29
30
31
32

Infection Control Plan, Emergency Disaster Plan, Facility records, Staff records and Resident records will be reviewed at a later date and time. Staff and resident interviews will also be conducted at a later time.
Annual Continuation required.

The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Civil Penalty assessed (See LIC 421BG) 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 emailed to the Licensee due to printer issues.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 05/23/2023 03:02 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: 05/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(a)

87355 Criminal Record Clearance (a) The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code section 1569.17 and shall have the authority to approve or deny a facility license, or employment, residence, or presence in the facility, based upon the results of such review. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and Guardian Review, the licensee did not comply with the section cited above in 1 out of 3 staff members were not background cleared which poses an immediate health, safety or personal rights risk to persons in care. Civil Penalty Assessed.
	POC Due Date: 05/24/2023
	Plan of Correction
1 2 3 4	Plan of Correction shall include a statement regarding future compliance. In addition, Licensee shall fill out at LIC 9098 Self-Certification form reading and understanding the regulation as it relates to Criminal Record Clearance.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 05/23/2023 03:02 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: 05/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on tour and observation, the licensee did not comply with the section cited above in that the laundry room was left open where chemicals were not locked which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/24/2023
	Plan of Correction
1 2 3 4	Plan of Correction shall include a written summary on future compliance. Licensee shall submit an LIC 9098-Self Certification.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 05/23/2023 03:02 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: 05/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(d)(2)

87307 Personal Accommodations and Services: (d) The following space and safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 of 1 kitchen sink had a cover on it and was clogged which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/30/2023
	Plan of Correction
1 2 3 4	Plan of Correction shall include unclogging that sink, submitting a plan for future compliance and submitting an LIC 9098 Self-Certification Form.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC809 (FAS) - (06/04)

Page: 5 of 5