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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701101
Report Date: 02/02/2023
Date Signed: 02/02/2023 11:31:20 AM


Document Has Been Signed on 02/02/2023 11:31 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
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: 5DATE:
02/02/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:Cleopatra GardienerTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Pang Lee and Avelina Martinez arrived at the facility on 02/02/2023 at 9:54 AM to conduct an unannounced Plan of Correction (POC) visit. LPAs Lee and Martinez met with Cleopatra Gardiener and explained the purpose of the visit. The purpose of this visit is to follow-up on plan of corrections that were due on 01/20/2023. During today's visit, LPAs toured and inspected the facility to ensure all deficiencies previously cited have been corrected.

Based upon this inspection, the LPAs observed the following:
  1. Deficiency cited under Title 22 Regulation 87309(a) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee.
  2. Deficiency cited under Title 22 Regulation 87468(2)(A) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee.
  3. Deficiency cited under Title 22 Regulation 87303(e)(2) has not been cleared. Licensee will complied with the terms of the POC by POC due date 02/03/2023. Residents bathroom water temperature was measured at 144.3 degrees Fahrenheit on 02/02/2023. As a result facility was cited and can be found on 809-D page.
  4. Deficiency cited under Title 22 Regulation 87457(c)(1) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee.
LPA Lee reminded Cleopatra Gardiener that the annual fee is passed due on 01/31/2023. A technical violation was given to the facility.

An exit interview was held, and a copy of this report, 809-D, LIC 9102 Technical Violation and appeal rights was given to the facility at the end of the visit.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023
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 2


Document Has Been Signed on 02/02/2023 11:31 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
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: 02/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/03/2023
Section Cited

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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
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Facility staff agrees to fix the water temperature by today, and send a written statement that the water temperature has been repaired. Facility staff agrees to add water temperature warning sign at kitchen sink. by POC date 02/03/2023. Staff will email to LPA Lee...
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Based on observation and inspection the kitchen water temperature measured at 131.9 and resident bathroom water temperature measured at 144.3. This posed a potential health and safety risk to residents in care.
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 pictures of repairs and sign posting. Staff agrees to conduct water temperature testing beginning 02/01/2023 to 02/28/2023. In addition, a weekly temperature log shall be emailed to LPA Lee.

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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) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023
LIC809 (FAS) - (06/04)
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