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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803898
Report Date: 06/05/2023
Date Signed: 07/07/2023 10:34:00 AM

Document Has Been Signed on 07/07/2023 10:34 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:PINK LADY CAREHOME, LLC.FACILITY NUMBER:
286803898
ADMINISTRATOR:ESPLANA B. ANGELINAFACILITY TYPE:
740
ADDRESS:39 VIA MARCIANATELEPHONE:
(707) 648-7983
CITY:AMERICAN CANYONSTATE: CAZIP CODE:
94503
CAPACITY: 6CENSUS: 4DATE:
06/05/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Care Giver, Maria SebastianTIME COMPLETED:
03:30 PM
NARRATIVE
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"AMENDED' .. This is an amended version of the original report created on June 5, 2023-SEE Below.

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Pink Lady Care home, LLC. for the purpose of conducting a Case Management-Annual Continuation Inspection. LPA was greeted at the door by Care Giver, Maria Sebastian and was granted access into the facility. LPA was made aware that the Licensees Administrator Certificate expired in October 26, 2022 and that there is no Administrator for the facility (See LIC 809D).

"AMENDED" LPA toured the laundry room and observed the unlocked laundry room and toxins that are stored in the cabinet were not locked and secured. Furthermore, the toxins were accessible to the residents in care. LPA educated the Licensee on the importance of ensuring that the laundry room is secured and toxins are inaccessible to residents in care (See LIC 809D & LIC 812-Observation/Photos). Civil Penalty assessed. File reviews were conducted. Medication Orders were reviewed during the Annual Continuation 4 of 4 resident files were reviewed during the Required 1 year inspection. LPA observed 1 out of 4 resident medication bottles not refilled. LPA learned that the Administrator is in the process of reaching out to the Primary Care Physician to notify of the medication refill (See LIC 809D-Observation/Photos). 4 out of 4 Needs and Services Plan were not current for residents in care (See LIC 809D). 1 out of 4 resident files did not have an updated LIC 602 (See LIC 9102-Technical Advisory) 5 of 5 staff files were reviewed. Staff interviews were conducted during the Required 1 year inspection. During the staff file review, LPA observed 4 out of 5 staff members are do not have sufficient hours of annual training as outlined in Health and Safety Code 1569.625 (b)(2) (See LIC 9102-Technical Violation). LPA requested the following documents to be sent:

(Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 06/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PINK LADY CAREHOME, LLC.
FACILITY NUMBER: 286803898
VISIT DATE: 06/05/2023
NARRATIVE
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-LIC 500
-Personnel Report
-Liability insurance
-Control of Property
-Register of resident

The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Civil Penalty assessed (See LIC 421M dated for June 5, 2023) Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with the Licensee via telephone, appeal rights provided and Caregiver provided this report.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 07/07/2023 10:34 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/05/2023 02:58 PM


Created By: Farhaan Sarangi On 06/05/2023 at 02:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PINK LADY CAREHOME, LLC.
FACILITY NUMBER: 286803898

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
Storage Space
(a) 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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above due to laundry room unlocked and toxins were left accessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.

Civil Penalty Assessed due to repeat violations.
POC Due Date: 06/12/2023
Plan of Correction
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Licensee shall train ALL staff on securing toxins and provide proof of training to Licensing. In addition, Licensee shall submit an LIC 9098- Self Certification form and plan for future compliance with this regulation.
Type A
Section Cited
CCR
87465(a)(2)
Incidental Medical and Dental Care Services
(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, 1 out of 4 resident medication bottles not refilled. LPA learned that the Administrator is in the process of reaching out to the Primary Care Physician to notify of the medication refill. This regulation poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2023
Plan of Correction
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Licensee shall train ALL staff on contacting the Prescribing Physician to secure refill orders. In addition, Licensee shall submit an LIC 9098- Self Certification form and plan for future compliance with this regulation.
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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/05/2023 03:15 PM - It Cannot Be Edited


Created By: Farhaan Sarangi On 06/05/2023 at 02:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PINK LADY CAREHOME, LLC.
FACILITY NUMBER: 286803898

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 out of 4 Needs and Services Plans were not current which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/12/2023
Plan of Correction
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Licensee shall ensure that ALL residents Needs and Services Plans are updated accordingly to reflect the Reappraisals that are being conducted. Licensee shall submit an LIC 9098-Self Certification and plan for future compliance.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 06/05/2023 03:15 PM - It Cannot Be Edited


Created By: Farhaan Sarangi On 06/05/2023 at 02:50 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PINK LADY CAREHOME, LLC.
FACILITY NUMBER: 286803898

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87405(a)
87405 Administrator - Qualifications and Duties

(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview the licensee did not comply with this section above due to the facility not having an Active Administrator. Furthermore, Licensee's Administrators Certificate expired in October 26, 2022. This regulation poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/12/2023
Plan of Correction
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Licensee shall provide WEEKLY updates regarding obtaining an Administrators Certificate and/or hiring a qualified Administrator. Furthermore, Licensee shall submit a plan for future compliance and an LIC 9098-Self Certification form.

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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2023


LIC809 (FAS) - (06/04)
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