286803898-7-7-2023-21-AS-FSAI-CTHNMH-20230707103510

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286803898
Report Date: 07/07/2023
Date Signed: 07/07/2023 10:35:26 AM

Document Has Been Signed on 07/07/2023 10:35 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. 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:	07/07/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Licensee, Jean Felix		TIME 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), Farhaan Sarangi arrived unannounced at Pink Lady Carehome, LLC for the purpose of conducting a Case Management-Other inspection regarding Amending a Civil Penalty. LPA issued a CORRECTED Civil Penalty (See LIC812-LIC421FC). LPA was greeted at the door by Caregiver, Princess Villanueva. Licensee, Jean Felix arrived 30 minutes later. During this Case Management-Other inspection, LPA reminded the Licensee that she is still missing an Administrator for the facility. LPA educated the licensee on Title 22 regulation regarding having an Administrator be onsite a sufficient number of hours a week. LPA learned that the facility just hired a new Administrator that will start on July 10, 2023. LPA provided the documents that need to be sent over to the Regional Office for this change to go into effect: LIC 308 Designation of Facility responsibility (designation of who is the administrator) Administrator Certificate First Aid Certificate Administrator Resume (in small facilities if possible) LIC 500 Personnel Report LIC 501 Personnel Record LIC 503 Health Screening Report - personnel (keep on facility staff file to be reviewed) TB test that shows "negative" (keep on facility staff file to be reviewed) LIC 508 Criminal Record Statement LIC 9182 Criminal Record Exemption Transfer Request Copy of Personal ID Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations) (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: 07/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023

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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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: 07/07/2023

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Furthermore, the Technical Support Program/Technical Support Unit was provided to the Licensee regarding assisting the facility to be in Title 22 compliance. However, the Licensee was not able to make communication with the Technical Support Analyst due to being busy with the residents. Licensee reiterated that she still wants the Technical Support/Technical Support Unit to be in compliance and to know what type of help they can give the facility. LPA discussed the facility still having a Plan of Corrections (POCS) needing to be sent to the Regional Office.

Licensee requested an extension to July 14, 2023. LPA gave a final extension to for July 14, 2023.

The Amended Civil Penalty was given along with the associated Amended Reports and appeal rights. Exit interview was conducted and a copy of this report was given to the Licensee.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023

LIC809 (FAS) - (06/04)

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