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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701101
Report Date: 03/06/2023
Date Signed: 03/08/2023 10:06:32 PM


Document Has Been Signed on 03/08/2023 10:06 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: 5DATE:
03/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Cleopatra GardenerTIME COMPLETED:
03:30 PM
NARRATIVE
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LPA Lee and LPM CCLee arrived at the facility to conduct a Pre Licensing visit to Sacramento Senior Living II for a change of ownership. Upon arrival to the facility LPA Lee and LPM CCLee observed a chain and lock on the gate which is the main exit out of the facility. The staff was advised that the gate cannot be locked and is not approved for a secured perimeter. Staff was advised that locks cannot be used in lieu of supervision if there is a resident that has a tendency to leave without notice. There shall be sufficient amount of staff in the facility to meet the resident's needs at all times. The staff understood and agreed the gate will not be locked anymore.

The LPA Lee observed that the kitchen refrigerator and pantry has lock preventing easy access. LPA Lee advised that refrigerator and pantry cannot be locked unless a waiver is requested with the Department. The staff did remove the locks on the fridge and pantry door.

The following deficiencies were cited. See LIC 809-D and appeal rights provided.


SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2023
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 03/08/2023 10:06 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: 03/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/06/2023
Section Cited

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87202(a) Fire Clearance
All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. The licensee did not ensure to have the main emergency exit accessible.
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POC cleared during the time of the visit. The staff removed the lock and chain at the time of the visit and stated will not use it anymore.
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 Based on observation and inspection LPA Lee observed a chain and lock on the faciity driveway gate. This posed a immediate health and safety risk to residents in care.


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Type A
03/06/2023
Section Cited

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87468.1 Personal Rights
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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POC cleared during the time of visit. Staff removed the locks on the fridge, freezer and the pantry.
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Based on obervation resident food refreigarotor and pantry was lock and made inaccessiable to resident in care. This pose an immediate health and safety 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) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2