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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701101
Report Date: 09/07/2022
Date Signed: 09/07/2022 11:46:40 AM


Document Has Been Signed on 09/07/2022 11:46 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, 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: 0DATE:
09/07/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Pang VueTIME COMPLETED:
12:00 PM
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On 9/7/22 at 8:45am Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Case Management inspection to ensure licensed facility still meets regulations for residents to be placed in the facility and to ensure facility still meets Title 22 regulations as the property was sold to a new owner on 8/18/22. LPA Gould received rent back agreement between the Licensee and the new property owner dated 8/18/22.

LPA Gould met with Licensee Pang Vue and together conducted a tour of the home. LPA observed no residents in place at the time of inspection. LPA observed the home's physical plant has changed since licensure. LPA observed one of the shared bedrooms had been converted into two private bedrooms and a new door has been installed in the resident hallway leading to three resident bedrooms, one shared and two single bedrooms. LPA informed licensee that a new fire clearance would be required prior to accepting any new residents.

LPA Tested the hot water temperature and recorded a temperature of 127 degrees F. and does not meet title 22 regulations. LPA observed a large amount of construction debris in the back yard that must be removed. LPA also requested that patio furniture be placed in the back yard for the benefit and use of residents. LPA also observed a trailer belonging to the new property owner in the driveway which must be removed prior to accepting new residents.

LPA requested the following documents to be submitted to the department to ensure the facility has an up to date fire clearance: submit new application (LIC-200) indicating request for new fire clearance and number of non-ambulatory residents the facility is seeking to serve, an updated facility sketch (LIC-999) and a completed Local Fire Inspection Information (LIC-9054) so the department may send the fire clearance request to the appropriate authority.

Per California Code of Regulations, Title 22, the following deficiencies have been cited during todays inspection.
A copy of this report and appeal rights were left at the facility. Report continued on LIC 9099-C
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2022
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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Document Has Been Signed on 09/07/2022 11:46 AM - 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: PANGO'S CARE HOME
FACILITY NUMBER: 342701101

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/12/2022
Section Cited

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Alterations to Existing Building or New Facilities: Prior to construction or alterations, all facilities shall obtain a building permit. This requirement was not met as evidenced by Licensee was unable to provide LPA with any bilding permits for the construction that divided and existing bedroom in the home which poses a
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potential health, safety and personal rights risk to residents in care.
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Type B
09/12/2022
Section Cited

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Transferability of License: The licensee shall notify the licensing agency and all residents receiving services, or their representatives, in writing as soon as possible and in all cases at least thirty (30) days prior to the transfer of the property or business, or at the time that a bona fide offer is made, whichever period is longer,
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as specified in Health and Safety Code Section 1569.191. This requirement was not met as evidenced by the home was sold on 8/18/22 and the department received no notification that the property had been sold within the required time frame of 30 days prior to the sale or when an offer has been made which poses a potential health, safety or personal rights risk to residents in care.
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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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2022
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: 09/07/2022
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Based on the inspection conducted by LPA Gould. The department has determined that the facility may not admit any new residents until the facility has obtained a new fire clearance and LPA Gould conducts a follow up case management inspection to ensure the facility meets all requirements of a licensed facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3