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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803898
Report Date: 06/06/2023
Date Signed: 06/06/2023 02:53:56 PM

Document Has Been Signed on 06/06/2023 02:53 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
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:
06/06/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Licensee, Jean FelixTIME COMPLETED:
03:00 PM
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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 Licensee, Jean Felix and was granted access into the facility. During the course of the Case Management-Annual Continuation Inspection, LPA provided Technical Assistance regarding the citations that were issued during the inspection as well as the Technical Support Program contact information.

During this Case Management-Annual Continuation inspection, LPA interviewed staff and residents in care. During the Pre-Licensing inspection, the Infection Control Plan was not discussed due to the facility not having one (See LIC 9102-Technical Violation). All staff will be trained in the Emergency Disaster and PPE training. Emergency Disaster plan was discussed with the Administrator. LPA was made aware that the facility is in the process of obtaining an Emergency Generator (See LIC 9102-Technical Violation). LPA discussed SOC 341 abuse reporting requirements with ALL staff members as well as Incident Reporting requirements.

No Deficiencies were cited during this Case Management-Annual Continuation Inspection. Exit interview was conducted and a copy of this report was given to the Licensee.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2023
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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