342701101-12-22-2021-27-AS-ATUK-C9XTBS-20211222133536

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701101
Report Date: 12/22/2021
Date Signed: 12/22/2021 01:35:46 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	PANGO'S CARE HOME		FACILITY NUMBER:	342701101
ADMINISTRATOR:	THAO, NENG RICHARD		FACILITY TYPE:	740
ADDRESS:	34 LOMA MAR CT		TELEPHONE:	(916) 508-6319
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95828
CAPACITY:	6	CENSUS:	DATE:	12/22/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Applicant Pany Lily Vue		TIME COMPLETED:	01:35 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	Announced Pre-licensing visit made via to this facility on 12/22/2021, LPA Anthony Tuck was met by the Applicant, Pang Lily Vue, who was briefly interviewed by LPA. It was learned that this facility will be licensed to serve up to (6) residents all ambulatory at any given time. This Applicant was also seeking a hospice waiver to accept and retain up to (1) hospice resident at any given time. There were no residents in care during today's Pre-licensing visit. Tour of the facility was conducted with applicant. Dining area, living area, and all other areas intended for resident use were toured and observed to be furnished and maintained in compliance at this time. Kitchen area was toured. Cabinets and drawers were opened and reviewed by LPA Tuck along with the Applicant. Knives and other sharp utensils were observed to be locked in a cabinet to make them inaccessible to the residents at all times. Food supply for 2-day perishable and 7-day nonperishable quantities were reviewed to make sure that this facility was in compliance at this time. Medication cabinet, located in the hallway area, was toured. First aid kit was observed to be present and contained all required components at this time. A tour of the (3) shared resident bedrooms was conducted. Furnishings and furniture intended for use by the residents were observed to be sufficient and able to meet the needs of the residents at this time. A tour of the resident bathroom was conducted. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees. Grab bars and nonskid mats were observed to be present and in compliance at this time. Laundry area was toured. All cleaning agents and detergents were observed to be locked and made inaccessible at this time. continued on LIC809C...

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PANGO'S CARE HOME	FACILITY NUMBER: 342701101
	VISIT DATE: 12/22/2021

NARRATIVE

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Linen closet, located in the hallway, was observed to contain a sufficient supply of towels and linens able to meet the needs of the residents at this time.
A tour of the exterior grounds was conducted. A review of the facility perimeter fence, side gates, and walkways were observed to not be maintained in compliance at this time. Gate latches were reviewed and observed to not be functional for allowed access for emergency response. All proper posters were posted on walls. All smoke detectors were observed however one smoke detector was not functioning properly during the pre-inspection. The carbon monoxide detector was operational. Fire extinguisher was fully charged and purchased on 09/16/2021. During the pre-inspection LPA observed the facility is not cleared for having a hospice waiver as the facility does not have a fire clearance for 1 non-ambulatory resident.

There were 9 deficiencies observed during today's Pre-licensing visit.
Facility had 1 defective smoke detector.
Garden hose obstruction in front yard and back yard.
Exposed water faucet pipe obstruction in backyard that may cause tripping hazard.
Exposed broken sprinkler pipes sticking up in ground located in backyard.
Backyard side fence in disrepair. Emergency exit gate/fence in disrepair with no pull cord.
Hallways leading to bathroom did not have night lights.
Cable wires for TV service not properly mounted to side of house.
Exposed bolts sticking up from ground in backyard.
Facility does not have a fire clearance for 1 non ambulatory as required for a hospice waiver.

Applicant will correct deficiencies by next visit date with LPA by January 13, 2022.

Component III interview was conducted with the Applicant and completed during today's Pre-licensing visit.

Exit Interview conducted with Applicant. A copy of this report was provided to the applicant upon exit.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

LIC809 (FAS) - (06/04)

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