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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803898
Report Date: 01/17/2024
Date Signed: 01/17/2024 06:43:40 PM


Document Has Been Signed on 01/17/2024 06:43 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:CECILE MENDOZAFACILITY TYPE:
740
ADDRESS:39 VIA MARCIANATELEPHONE:
(707) 648-7983
CITY:AMERICAN CANYONSTATE: CAZIP CODE:
94503
CAPACITY:6CENSUS: 4DATE:
01/17/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:53 PM
MET WITH:Jean Felix, LicenseeTIME COMPLETED:
05:34 PM
NARRATIVE
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced and met with care staff, Erlinda Sonaco. During a complaint investigation LPA discovered an additional staff (S1) who has a fingerprint clearance but their fingerprint clearance is not associated to this facility as required. In addition, LPA observed a shut-off water notice on the door and at 1:50pm LPA verified the facility has no water as it has been shut off. LPA verified there was plenty of bottle drinking water on hand. Licensee Jean Felix arrived and provided proof that the minimum amount to restart service has been paid and at about 3:55pm the water was restored to the property.

A civil penalty was assessed for $100.00 for staff S1 not being properly associated to this facility.

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 appeal of rights provided.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024
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 01/17/2024 06:43 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: 01/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/18/2024
Section Cited
CCR
87211(d)

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87211(d) Reporting Requirements(d) The licensee shall notify the Department, the State Long-Term Care Ombudsman, all residents, and, if applicable, their representatives, in writing within two business days of any of the following specified events, or knowledge thereof:(5) A utility company has sent a notice of intent to terminate electricity, gas, or water service on the property within not more than 15 days of the notice.
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Facility provided proof they had paid the minimum amount to restart the water service and service was restored before 4pm. Facility to send in written
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This requirement was not met as evidenced by: during inspection LPA discovered the facilities water had been turned off for non payment. This is an immediate risk to the health and safety of residents in care.
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plan they have a payment plan to ensure they become current on their utility bills. Proof of plan due 1/18 and follow up with LPA again by 2/1/2024 for update on any outstanding amounts due.
Type B
01/19/2024
Section Cited
CCR87355(e)(2)

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87355(e)(2) Criminal Record Clearance. Prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall request a transfer of a criminal record clearance from another facility or Trustline
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Facility completed the required forms and sent to regional office during visit. Facility to send in a written plan they understand regulation and
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This requirement was not met as evidenced by: during ee roster record review and confirmation with regional office, staff S1 was fingerprint cleared but not associated to this facility- This is a potential risk to the health and safety of all residents in care.
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how facility will ensure they stay in compliance.
POC due date 1/19/2024

Attention LPA Araceli Canela
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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024
LIC809 (FAS) - (06/04)
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