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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604858
Report Date: 05/23/2025
Date Signed: 05/23/2025 05:19:04 PM

Document Has Been Signed on 05/23/2025 05:19 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:PURPLE PASTA CARE HOME LLCFACILITY NUMBER:
374604858
ADMINISTRATOR/
DIRECTOR:		PANKEY, PENELOPEFACILITY TYPE:
740
ADDRESS:6216 PEMBROKETELEPHONE:
(619) 728-8704
CITY:SAN DIEGOSTATE: CAZIP CODE:
92115
CAPACITY: 6CENSUS: 4DATE:
05/23/2025
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Administrator Penelope PankeyTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analysts (LPA) Amy Rodgers conducted an unannounced post annual visit. The facility file was reviewed prior to the visit. LPAs were greeted by, identified themselves to, and explained the purpose of the visit Care giver Eduadro Hernandez. Administrator Penelope Pankey later joined the visit.

LPA toured the facility and inspected each room of the facility, including resident rooms, bathrooms for resident and staff use, kitchen, common areas, and outside space. LPA did not observe any aspects of delayed egress or secured perimeter. The facility was found to be clean, safe, and in good repair with no pathway obstructions. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. LPA also observed locked storage for resident medications and resident and staff files. Medications were stored in their original container and locked, made inaccessible to clients. LPA observed a minimum of a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. LPA observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs.

LPA reviewed multiple resident records. There were documents missing for all four resident: Resident #1, Resident #2, Resident #3 and Resident #4 and citations were issued during todays visit.

(Continued on page 809-C)
NAME OF LICENSING PROGRAM MANAGER: Denise Powell
NAME OF LICENSING PROGRAM ANALYST: Amy Rodgers
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2025
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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Document Has Been Signed on 05/23/2025 05:19 PM - It Cannot Be Edited


Created By: Amy Rodgers On 05/23/2025 at 04:13 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PURPLE PASTA CARE HOME LLC
FACILITY NUMBER: 374604858

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in that 2 of 2 staff did not have criminal record clearance which poses an immidiate potential health risk to 4 of 4 residents in care.
POC Due Date: 05/23/2025
Plan of Correction
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LPA asked Administrator to have S1 and S2 leave the facility and can informed the Administrator staff can not return until criminal records clearance has been processed. Administraor will call LPA and inform them when Staff is back to work
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.
Denise Powell
NAME OF LICENSING PROGRAM MANAGER:
Amy Rodgers
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/23/2025 05:19 PM - It Cannot Be Edited


Created By: Amy Rodgers On 05/23/2025 at 04:13 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PURPLE PASTA CARE HOME LLC
FACILITY NUMBER: 374604858

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based record review, the licensee did not comply with the section cited above in 2 of 4 residents (R1, and R2,) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2025
Plan of Correction
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Administrator agreed to email LPA all documets by POC date
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review , the licensee did not comply with the section cited above in4 of 4 residents (R1-R4) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2025
Plan of Correction
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Administrator agreed to email LPA all documets by POC date
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Denise Powell
NAME OF LICENSING PROGRAM MANAGER:
Amy Rodgers
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/23/2025 05:19 PM - It Cannot Be Edited


Created By: Amy Rodgers On 05/23/2025 at 04:13 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PURPLE PASTA CARE HOME LLC
FACILITY NUMBER: 374604858

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

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 1 of 4 residents (R3) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2025
Plan of Correction
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Administrator agreed to email LPA all documets by POC date
Type B
Section Cited
HSC
1569.695(e)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency:

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 of 4 residents in care (R1-R4) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2025
Plan of Correction
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2
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Administrator agreed to review regualtion and email LPA all documets by POC date
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Denise Powell
NAME OF LICENSING PROGRAM MANAGER:
Amy Rodgers
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2025


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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: PURPLE PASTA CARE HOME LLC
FACILITY NUMBER: 374604858
VISIT DATE: 05/23/2025
NARRATIVE
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 During the visit, LPA determined that Staff 1(S1) and Staff 2 (S2) was not associated to the facility and did not have an active fingerprint clearance. [Administrator was provided with an LIC811 Confidential Names List to identify S1 and S2 ] Interviews with S1 and S2 and the Administrator revealed that S1 and S2 had been working at the facility for more than 5 calendar days. LPA notified Administrator that S1 could not be present or working at the facility until all was associated to the facility. LPA observed S1 and S2 leave the facility during the visit.

The following deficiencies were cited for missing medical assessments, missing admissions agreements, missing pre-placement agreements and for staff without criminal background clearance and noted on the attached LIC809-D pages. Additionally, a civil penalty in the amount of $500 was assessed for staff without a criminal background clearance and noted on the attached LIC421BG form.

An exit interview was conducted with Administrator Penelope Pankey , whose signature below confirms receipt of a copy of this report, the LIC811, LIC 809-D's and the LIC421BG and the Licensee Appeal Rights (LIC9058 3/22).
NAME OF LICENSING PROGRAM MANAGER: Denise Powell
NAME OF LICENSING PROGRAM ANALYST: Amy Rodgers
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025
LIC809 (FAS) - (06/04)
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