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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803898
Report Date: 01/21/2026
Date Signed: 01/21/2026 02:02:13 PM

Document Has Been Signed on 01/21/2026 02:02 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/
DIRECTOR:		MARY GRACE DEFEOFACILITY TYPE:
740
ADDRESS:39 VIA MARCIANATELEPHONE:
(707) 731-2345
CITY:AMERICAN CANYONSTATE: CAZIP CODE:
94503
CAPACITY: 6CENSUS: 6DATE:
01/21/2026
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Jean Felix (Licensee)TIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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Licensing Program Analysts (LPAs) Julie Florio and Marisol Cuadra arrived at this facility unannounced to conduct a Case Management Legal/Non-Compliance visit and was greeted by staff. Jean Felix, Licensee arrived later. LPAs were following up on items that were concerning and ensure compliance with Non-Compliance Conference dated 11/19/25:

HSC 1569.605 - Liability On and after July 1, 2015, all residential care facilities for the elderly - Facility failed to have a current liability insurance with required amounts. The Licensee agrees to provide a copy of the facility current liability insurance.

CCR 87213 - Finances - The licensee shall have a financial plan that conforms to the requirements of Section 87155 by not later than April 15, 2026. The Department requires Licensee to submit quarterly financial statements including January, February and March 2026 operational costs of the facility, which includes the following:
1. Profit & Loss statements for the months identified above or in the report.
2. Rent, payroll, income & expense third party documents such as utility statements (gas, electric, etc)
supporting the amounts entered on the LIC401
3. Balance sheet for January, February and March 2026, and supporting third party documents, such as liabilities (loans, credit cards) supporting the amounts entered on LIC403
4. All Bank statements used for the operation of the facility for the months identified, cash reserve documents for the facility's emergency needs.
Continued on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 01/21/2026
NARRATIVE
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Continued from LIC809...
5. Current General Liability Insurance and Workers Compensation Insurance.
6. Any financial records deemed relevant to support the licensee has an adequate financial plan, as required by law, such as Form 941, the Employer's Quarterly Federal Tax Return, & Quarterly Contribution Return and Report of Wage - DE 9.

Previously an office meeting was conducted on 11/19/2025 in the Santa Rosa Regional Office, where other deficiencies were discussed including Fire Clearance. During today's visit, LPAs toured the facility and observed the dining room was converted to a resident's room. Resident (R1) is occupying dining room, which is not cleared by the Fire Department as a resident room. The facility fire clearance dated 5/5/2020 allows for two ambulatory, two non-ambulatory and two bedridden residents. LPAs reminded the Licensee that they were not allowed to have residents in the dining room due to the room was not cleared by the fire department as a resident's room. Licensee agreed to submit STD850 form requesting an updated fire clearance along with an updated facility sketch indicating the use of dining room as a resident room for the Fire Marshall to assess bedrooms to grant or deny fire clearance. Licensee is operating outside the limitation of the license by accepting a resident in a non-cleared room. As a result of the fire clearance violation, an immediate civil penalty in the amount of $500 is issued today.

LPAs confirmed that the residents were safe and secure and that there was proper amounts of food stores, power, water and heat. Facility was a comfortable temperature and had power, water, and heat. Food stores were sufficient to sustain residents in care for seven (7) days as required per regulation. At approximately 11:58am, LPAs observed screen in sliding door located in exit door #3 in shared room #4 as well as door bottom strip needs to be repaired/replaced. Also, one out of two garbage cans located in shared room #4 was observed uncovered with no lids, and containing dirty depends. LPAs will issue a technical violation for Maintenance & Operation and have a conversation with the Licensee regarding regulation indicating: "The facility shall be clean, safe, sanitary and in good repair at all times". Continued on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/21/2026 02:02 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 01/21/2026 at 01:13 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: 01/21/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/22/2026
Section Cited
CCR
87202(a)

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(a) All facilities shall maintain a fire clearance approved by...fire department. Prior to accepting or retaining any of the following types of persons the licensee shall notify the licensing agency & obtain an appropriate fire clearance approved: This requirement is not met as evidenced by:
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Licensee agreed to submit STD850 form requesting an updated fire clearance along with an updated facility sketch indicating the use of dining room as a resident room for the Fire Marshall to assess bedrooms to grant or deny fire clearance. ***Immediate civil penalty in the amount of $500
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Based on LPAs/Licensee observation, interview and record review, the licensee did not comply with the section cited above in all by having R1 occupying a non-cleared room which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
01/22/2026
Section Cited
CCR87632(a)

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Hospice Care Waiver. In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. This requirement has not been met as evidence by:
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Licensee agrees to submit to CCL required documentation to review facility hospice care exception request to clear the citation.
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Based on LPAs/Licensee observation, interview and record review, the licensee did not comply with the section cited above by having three residents (R1, R2 & R3) receiving hospice services without obtaining an exception or hospice waiver increase approval from the Department, which is a potential risk to the health & safety of the 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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2026


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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PINK LADY CAREHOME, LLC.
FACILITY NUMBER: 286803898
VISIT DATE: 01/21/2026
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Continued from LIC809C...

Additionally, LPAs observed three residents (R1, R2 & R3) are currently receiving hospice services without obtaining an exception or hospice waiver increase approval from the Department. Based on records review, the facility License dated 5/27/2020 indicates a hospice waiver approval for two residents. According to the Licensee, they were in the process to submit an exception for the third resident receiving hospice services. LPAs discussed with the Licensee, hospice care waiver regulation and the importance to obtain a facility hospice care waiver/exception from the Department prior to accept or retain a resident receiving hospice services.

LPAs provided required documentation to be submitted to CCL for resident's exception review:

- Written request for hospice exception that includes resident information (name, DOB, etc) why resident is going on hospice, and how staff will provide care for the resident in a way that does not impact other residents.
- Current physician’s report (LIC 602), and updated appraisal and care plan that addressees all provisions of care to ensure client's needs are being met.
- What hospice agency will be providing care for the resident including frequency and type of service.
- Hospice Care Plan.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. An immediate civil penalty in the amount of $500.

Exit interview conducted with Licensee and a copy of this report was given.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026
LIC809 (FAS) - (06/04)
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