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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803898
Report Date: 05/08/2026
Date Signed: 05/08/2026 04:54:32 PM

Document Has Been Signed on 05/08/2026 04:54 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
SANTA ROSA RO, 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: 2DATE:
05/08/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Teresita Buenavista, CaregiverTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
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At approximately 2:30 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and quarterly non-compliance visit. LPA met with Teresita Buenavista, Caregiver. Licensee was contacted via telephone by caregiver and was unable to attend today's visit. LPA attempted to contact Administrator and left them a voicemail. LPA did not receive a returned phone from Administrator during visit. Neither Licensee nor Administrator were present for today's visit. LPA was informed the facility is closing and Licensee is working on issuing 60-day notices informing the residents formally of the facility's closure. LPA was informed that Licensee is assisting the current residents with new facility placement.

Facility is a Residential Care Facility for the Elderly (RCFE) with two (2) residents in care. Facility has a Dementia Care Plan, a Hospice waiver for two (2), and is approved for 4 non-ambulatory residents, two (2) of whom may be bedridden. Facility currently has one (1) Hospice residents in care.

Facility is currently on Non-Compliance for the following reasons:
Lack of Liability Insurance in the proper amounts.
Lack of proper funds to properly maintain facility.

LPA toured the facility to ensure 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.

Continued on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Julie Florio
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2026
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PINK LADY CAREHOME, LLC.
FACILITY NUMBER: 286803898
VISIT DATE: 05/08/2026
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Continued from LIC809...

Smoke and carbon monoxide detectors were tested and were operational during inspection. The fire extinguisher was observed fully charged and was last inspected 02/2025. Facility telephone was tested an operational during inspection.

LPA reviewed files for the two residents in care. Both contained all the required paperwork per regulation. Caregiver informed LPA that they do not have access to the staff files or the centrally stored medications. LPA was unable to review staff files or medications during today's inspection. Caregiver informed LPA that one resident manages their own medications and the other has them pre-poured in a medication container which was observed stored in an unsecured drawer in the unlocked laundry room. LPA and LPM were able to confirm the facility currently has adequate staffing. Facility does not handle P&I cash resources for residents.

LPA will return to RO to conduct further file review and consult with LPM. LPA may return at a later date to issue citations. The Department will request quarterly financial auditing documents at a future date.

No deficiencies cited during today's inspection.

Exit interview conducted with Caregiver, whose signature on form confirms receipt of documents.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Julie Florio
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026
LIC809 (FAS) - (06/04)
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