<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701101
Report Date: 01/19/2023
Date Signed: 01/19/2023 06:10:48 PM


Document Has Been Signed on 01/19/2023 06:10 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
SACRAMENTO AC/SC, 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: 6DATE:
01/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Cleopatre GardienerTIME COMPLETED:
06:30 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
Licensing Program Analyst (LPAs) Pang Lee and Avelina Martinez arrived at the facility to conduct an unannounced annual inspection on 01/19/2023. LPAs met with Cleopatre Gardiener and explained the purpose of the visit. Cleopatre Gardiener assisted with today’s visit.

LPAs inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. This facility is a single story building licensed to serve four (4) non-ambulatory residents, (2) ambulatory and (1) hospice waiver. LPAs observed the facility to be free of odor, clean and in good repair. LPAs observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present.

LPAs observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured in the kitchen and bathroom. The kitchen water temperature measured at 131.9 degrees and the resident bathroom water temperature measured at 127.8 degrees. Fire extinguishers, smoke and carbon monoxide detectors are in good repair. Facility thermostat observed at 75 degrees Fahrenheit. LPAs checked medication storage and found medication to be locked away and inaccessible to clients. First aid kit was incomplete; the first aid kit was missing a manual. In addition, the facility was missing Publication 475. LPAs requested client and staff files for review. LPAs reviewed (3) resident files and (1) staff files. Resident files were not complete. Two resident files were incomplete and two staff files were missing. Toxins were made accessible to clients in care. Toxins are stored in the laundry room, however the laundry door nob locks are accessible to residents in care, and residents are able to unlock the door nob and get to the toxins.

Continued...
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


Document Has Been Signed on 01/19/2023 06:10 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
SACRAMENTO AC/SC, 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: 01/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/02/2023
Section Cited

1
2
3
4
5
6
7
87457(c)(1)Pre-Admission Appraisal - General; Prior to admission a determination of the prospective resident's suitability for admission shall be completed...This requirement is not met as evidence by; based on observation and record reviews
1
2
3
4
5
6
7
Facility staff agrees to complete all Admission appraisals by POC date 02/02/2023. Facility staff shall email all completed appraisals to LPA Lee by 02/02/2023 close of business 5PM.
8
9
10
11
12
13
14
the facility did not complete pre-admission appraisal. Documents was signed by the applicant and lincensee but the rest of the form was blank. This pose a potiential health and saftey risk to R1.
8
9
10
11
12
13
14
Type B
02/02/2023
Section Cited

1
2
3
4
5
6
7
87465(8)(A) Incidental Medical and Dental Care:If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained...A current edition of a first aid manual approved by the American Red Cross. This requirment was not met as evidence by: Based on on observation
1
2
3
4
5
6
7
Facility staff agrees to have a first aid manual by POC Date 02/02/2023. Facility staff agrees to email a picture of the first aid manual to LPA Lee by 02/02/2023 close of business 5 PM
8
9
10
11
12
13
14
The first aid kit was missing an approve manual. This posed a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
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) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 01/19/2023 06:10 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
SACRAMENTO AC/SC, 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: 01/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/23/2023
Section Cited

1
2
3
4
5
6
7
87468 Personal Rights:(2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints...Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475)
1
2
3
4
5
6
7
Facility staff agrees to post Pub 475 by POC Date 01/23/2023. Facility staff shall email a picture of the poster posted in the facility by POC date 01/23/2023 close of business 5 PM.
8
9
10
11
12
13
14
This requirement was not met as evidence by: Based on observation the facility did not have PUB 475 poster posted in the facility. This posed a potential health and safety risk.
8
9
10
11
12
13
14
Type B
01/20/2023
Section Cited

1
2
3
4
5
6
7
87303(e)(2) Maintenance and Operation Water supplies and plumbing fixtures shall be maintained as follows: Faucets used by residents for personal care such as shaving and grooming shall deliver hot water...This requirement was not met as evidence by
1
2
3
4
5
6
7
Facility staff agrees to fix the water temperature by today. Staff agrees to email a water temperature log to LPA Lee by POC Date 01/20/2023 close of business 5 pm.
8
9
10
11
12
13
14
Based on observation and inspection the kitchen water temperature measured at 131.9 and resident bathroom water temperature measured at 127.8. This posed a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
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) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 01/19/2023 06:10 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
SACRAMENTO AC/SC, 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: 01/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/20/2023
Section Cited

1
2
3
4
5
6
7
87309(a) Storage Space: Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients... This requirement was not met as evidence by:
1
2
3
4
5
6
7
The facility staff agrees to: to change the lock by POC date 01/20/2023. Facility staff shall email a picture of the corrected door lock by 01/20/2023 by close of business 5PM to LPA Lee.
8
9
10
11
12
13
14
Based on observation and inspection toxins were made assessable to residents to care. Residents are able to unlock door. This posed an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Type B
02/03/2023
Section Cited

1
2
3
4
5
6
7
87412(g)(1) Personnel Records:All personnel records shall be maintained at the facility and shall be available to the licensing agency for review...he licensee shall be permitted to retain such records in a central administrative location provided that they are readily available to the licensing agency...
1
2
3
4
5
6
7
The facility staff agrees to conduct a personal record training by POC date 02/03/2023. Facility staff shall email training documentation to LPA Lee by 02/03/2023 by close of business 5 PM.
8
9
10
11
12
13
14
This requirement was not met as evidence by: based on observation and file reviews: Two staff files are missing. This posed a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
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) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: PANGO'S CARE HOME
FACILITY NUMBER: 342701101
VISIT DATE: 01/19/2023
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
26
27
28
29
30
31
32
The facility has one main entry Covid-19 screening point, and has a Covid-19 mitigation plan. The facility has a 30 day supply of PPE, and conduct daily cleaning. The facility furniture is spaced six feet apart.
In addition, LPAs were made aware that this property was sold last year August of 2022. LPA Lee requested a copy of the lease back agreement and shall be emailed to LPA Lee by 01/20/2023 by close of business 5PM.

Moreover, the following documents shall be emailed to LPA Lee by 01/23/2023 by close of business 5PM.
(1) LIC308 Designation of Administrative Responsibility
(2) LIC500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance
(6) Administrative Organization (LIC309)
(7) Liability Insurance
(8) Lease Back Agreement

As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the 809 D page. An exit interview was conducted, and a copy of this 809 report, 809 D Page, and Appeals rights were provided to the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5