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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701101
Report Date: 04/14/2022
Date Signed: 04/14/2022 04:48:02 PM


Document Has Been Signed on 04/14/2022 04:48 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:PANGO'S CARE HOMEFACILITY NUMBER:
342701101
ADMINISTRATOR:PANG LILY VUEFACILITY TYPE:
740
ADDRESS:34 LOMA MAR CTTELEPHONE:
(916) 508-6319
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 1DATE:
04/14/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
02:58 PM
MET WITH:Pang VueTIME COMPLETED:
04:46 PM
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Licensing Program Analyst (LPA) Anthony Tuck arrived to conduct an unannounced post licensing inspection on 04/14/2022. LPA met with Pang Vue and explained the purpose of the visit. Pang Vue is the Administrator and holds certificate# 6060517740 that expires on 05/22/2023.

This facility is a single story building licensed to serve five (5) ambulatory and one (1) non-ambulatory resident. Facility is licensed for 1 hospice waiver. LPA toured the physical plant including but not limited to two resident bedrooms, two resident bathrooms, garage and backyard area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present.

LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at (109.2) degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers and smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguisher last serviced 01/12/2022. Thermostat observed at (72) degrees Fahrenheit.

LPA observed centrally stored medications, toxins and sharp knives kept locked and inaccessible to clients. LPA reviewed resident and staff files, including criminal record clearances. LPA reviewed Fingerprint clearance and associations to the facility. First aid kit was checked and is complete.

The following forms need updating and were received on 04/14/2022:
LIC 500, LIC 9020, Liability insurance certificate

Exit interview held with Pang Vue and a copy of report given at the conclusion of the visit.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
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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