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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604858
Report Date: 04/13/2026
Date Signed: 04/13/2026 09:12:22 PM

Document Has Been Signed on 04/13/2026 09:12 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: 5DATE:
04/13/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Caregiver Leticia Manuel and Administrator Penelope PankeyTIME VISIT/
INSPECTION COMPLETED:
09:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen made an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Leticia Manuel. LPA then met with Licensee/Administrator Penelope Pankey, who arrived shortly after.

LPA performed a welfare check on residents in care and interviewed facility staff. LPA reviewed the care records for all residents in care, and the personnel files of all active staff. LPA, accompanied by Licensee’s staff, also toured the interior and exterior of the facility, and inspected all common areas and resident rooms.

According to the facility’s license: The facility has a maximum capacity for six (6) residents, of whom up to one (1) may be non-ambulatory and up to one (1) more may be either non-ambulatory or bedridden. Only shared Bedroom #5, per the facility sketch, is approved to house non-ambulatory or bedridden residents. Up to two (2) residents may be under hospice care at any given time. Per LPA observation and manager interview and informed by LIC602 Physician’s Reports: During today’s inspection, there were a total of five (5) residents in care, of whom two (2) residents [Resident #1 (R1) and Resident #2 (R2)] were bedridden, which exceeds the bedridden capacity specified in the facility’s prior approved fire clearance and facility license. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.]

Additionally, upon LPA’s arrival at the facility, neither R1 nor R2 were occupying Bedroom #5. Only one (1) resident, R2, was under hospice care. During today’s visit, Licensee communicated with and secured consent from R1’s responsible person (RP), then moved R1 to Bedroom #5, as required. [CONTINUED ON LIC 809-C, 2 of 3]
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 15
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)
Page: 2 of 15
Document Has Been Signed on 04/13/2026 09:12 PM - It Cannot Be Edited


Created By: Dang Nguyen On 04/13/2026 at 05:32 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: 04/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87204(a)
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, LPA observation, and manager interview, in continuing to retain 1 of 5 residents (R2), who put the facility over its bedridden capacity, Licensee operated the facility beyond the conditions and limitations specified on the license. This posed an immediate health and safety risk to persons in care.
POC Due Date: 04/14/2026
Plan of Correction
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Per the administrator, R2 can turn and reposition themselves in bed and may qualify as non-ambulatory if reassessed. Licensee agreed to contact R2’s physician to see if they are willing to amend R2’s LIC602 to show them as non-ambulatory and not bedridden, in which case Licensee would E-mail a copy of the updated LIC602 to LPA and relocate R2 to Bedroom #5. Should the above not succeed, Licensee agreed to serve R2 and their responsible person (RP) with a 30-day eviction notice. Licensee agreed to E-mail either the updated LIC602 showing R2 as non-ambulatory or a copy of the 30-day notice to LPA, by the POC due date.
Type A
Section Cited
CCR
87615(a)(2)
87615 Prohibited Health Conditions: “(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (2) Gastrostomy tubes.” This requirement was not met, as evidenced by:
Deficient Practice Statement
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Based on records review, LPA observation, and manager interview, in retaining 1 of 5 residents (R2) with an active gastronomy tube, Licensee had a resident in care with a prohibited health condition. This posed an immediate health risk to persons in care.
POC Due Date: 04/14/2026
Plan of Correction
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Licensee agreed to first see if R2’s physician is willing to reclassify R2 as non-ambulatory. If yes, then Licensee will submit an Exception Request packet to CCLD for R2’s gastrotomy. If no, then Licensee agreed to serve R2 and their responsible person (RP) with a 30-day eviction notice. Licensee agreed to E-mail either the Exception Request or the 30-day notice to LPA, by the POC due 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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2026


LIC809 (FAS) - (06/04)
Page: 3 of 15
Document Has Been Signed on 04/13/2026 09:12 PM - It Cannot Be Edited


Created By: Dang Nguyen On 04/13/2026 at 05:32 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: 04/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, Licensee did not ensure that cleaning solutions and tools which could pose a danger to residents were in locked storage and not left unattended. This posed an immediate health and safety risk to 4 of 5 residents (R1, R2, R3, R5) in care.
POC Due Date: 04/13/2026
Plan of Correction
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During today's visit, LPA handed the cleaning solutions, fertilizer, and tools to staff to be locked away. This resolved the immediate risk. Licensee agreed to retrain all current staff on what items constitute hazards and on their correct storage, and to E-mail the training sign-in sheet to LPA by 05/13/2026.
Type A
Section Cited
CCR
87555(b)(25)
General Food Service Requirements
(25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, Licensee did not ensure that detergents, cleaning compounds, and similar substances were stored in areas separate from food supplies. This posed an immediate health and safety risk to 5 of 5 residents (R1 through R5) in care.
POC Due Date: 04/13/2026
Plan of Correction
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During today's visit, staff moved the chemicals and food to seperate/segregated storage areas. This resolved the immediate risk. Licensee agreed to retrain all current staff on what items constitute hazards and on their correct storage, and to E-mail the training sign-in sheet to LPA by 05/13/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2026


LIC809 (FAS) - (06/04)
Page: 4 of 15
Document Has Been Signed on 04/13/2026 09:12 PM - It Cannot Be Edited


Created By: Dang Nguyen On 04/13/2026 at 05:32 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: 04/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, Licensee did not ensure that centrally stored medicines were kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This posed an immediate health and safety risk to 5 of 5 residents (R1 through R5) in care.
POC Due Date: 04/13/2026
Plan of Correction
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During today's visit, LPA handed the unsecured medicines to staff to be relocated to a lockbox and a locked cabinet. This resolved the immediate risk. Licensee agreed to retrain all current staff on expectations regarding safe storage of centrally stored medications, and to E-mail the training sign-in sheet to LPA by 05/13/2026.
Type A
Section Cited
CCR
87203
87203 Fire Safety: “All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.” This requirement was not met, as evidenced by:
Deficient Practice Statement
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Based on LPA observation and manager interview, Licensee did not maintain the facility in continuous conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire. This posed an immediate safety risk to 5 of 5 residents (R1 through R5) in care.
POC Due Date: 04/14/2026
Plan of Correction
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During today’s visit, the Smoke Alarm in Bedroom #4 was restored. Licensee agreed to either have the facility’s fire extinguisher professionally-serviced or to purchase a new extinguisher, and to send a photo of either the updated service tag or the purchase receipt to LPA, by the POC due 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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2026


LIC809 (FAS) - (06/04)
Page: 5 of 15
Document Has Been Signed on 04/13/2026 09:12 PM - It Cannot Be Edited


Created By: Dang Nguyen On 04/13/2026 at 05:32 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: 04/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(b)(2)(C)
Infection Control Requirements
(b) In addition to subsection (a), when one or more residents in the facility are diagnosed with a contagious disease, the following shall apply: (2) All staff and volunteers providing direct care to a resident who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth. PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection. (C) The licensee shall ensure all staff and volunteers are trained in the proper use of all required PPE prior to being around residents and annually thereafter.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and staff interview, Licensee did not ensure that 5 of 5 staff (S1 through S5) received training on the proper use of all required PPE within the last year. This posed a potential health risk to 5 of 5 residents (R1 through R5) in care.
POC Due Date: 05/13/2026
Plan of Correction
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Licensee agreed to train all current staff on PPE. The training will include hands-on practice and will cover: a) handwashing, b) how and how often to disinfect commonly touched surfaces, c) how to correctly don and doff surgical masks, N-95 respirators, face shields, gowns, and gloves, d) how perform an N-95 seal check, and e) how to correctly set up a COVID-19 isolation bedroom. Licensee agreed to E-mail the training sign-in sheet to LPA, by the POC due date. Going forward, Licensee agreed to repeat this training at least annually.
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, Licensee did not keep the facility's backyard in a clean condition. This posed a potential personal rights risk to 5 of 5 residents (R1 through R5) in care.
POC Due Date: 05/13/2026
Plan of Correction
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Licensee agreed to discard the excess unused assistive mobility devices that are in the facility's backyard, or to at least relocate them from the premises. Licensee agreed to send photographs of the facility's backyard, after this is done, to LPA, by the POC due 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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2026


LIC809 (FAS) - (06/04)
Page: 6 of 15
Document Has Been Signed on 04/13/2026 09:12 PM - It Cannot Be Edited


Created By: Dang Nguyen On 04/13/2026 at 05:32 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: 04/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA measurement via thermometer, Licensee did not maintain hot water temperature controls to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degrees F and not more than 120 degrees F. This posed a potential health and personal rights risk to 5 of 5 residents (R1 through R5) in care.
POC Due Date: 05/13/2026
Plan of Correction
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During today’s inspection, adjustments were made to the facility’s water heater settings, which brought said water taps back into the complaint temperature range. The Plan of Correction is Satisfied.
Type B
Section Cited
CCR
87613(a)(2)(A)
87613 General Requirements for Restricted Health Conditions: “(a) Prior to admission of a resident with a restricted health condition, the licensee shall: (2) Ensure that facility staff who will participate in meeting the resident’s specialized care needs complete training provided by a licensed professional sufficient to meet those needs. (A) Training shall include hands-on instruction in both general procedures and resident-specific procedures.” This requirement was not met, as evidenced by:
Deficient Practice Statement
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3
4
Based on records review and manager interview, 1 of 5 residents (R3) had a restricted health condition, but Licensee did not have proof that 5 of 5 facility staff (S1 through S5), who will participate in meeting the resident’s specialize care needs, completed training provided by a licensed professional, which included hands-on instruction in both general procedures and resident-specific procedures. This posed a potential health risk to persons in care.
POC Due Date: 05/13/2026
Plan of Correction
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2
3
4
Licensee is a Registered Nurse, and agreed to lead a hands-on in-service training for all current caregivers on at least the following Restricted Health Conditions which are present at the facility: Diabetes (including blood sugar basics, controlled carbohydrate diets, use of glucometer, use of insulin flex pens and other diabetic medications, signs and symptoms of hypoglycemia/hyperglycemia, and diabetic emergencies requiring medical intervention.) Licensee agreed to E-mail the staff training sign-in sheet to LPA, by the POC due 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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2026


LIC809 (FAS) - (06/04)
Page: 7 of 15
Document Has Been Signed on 04/13/2026 09:12 PM - It Cannot Be Edited


Created By: Dang Nguyen On 04/13/2026 at 05:32 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: 04/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review and manager interview, Licensee did not possess a completed and signed health screening for 6 of 6 staff (S1 through S6). This posed a potential health and safety risk to 5 of 5 residents (R1 through R5) in care.
POC Due Date: 05/13/2026
Plan of Correction
1
2
3
4
Licensee agreed to coordinate with staff to complete an LIC503 Health Screening form wth negative TB test result / chest x-ray for S1 through S6, and E-mail copies of such to LPA, by the POC due 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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2026


LIC809 (FAS) - (06/04)
Page: 8 of 15
Document Has Been Signed on 04/13/2026 09:12 PM - It Cannot Be Edited


Created By: Dang Nguyen On 04/13/2026 at 05:32 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: 04/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review and manager interview, Licensee did not maintain a personnel record for 1 of 5 staff (S5). This posed a potential health risk to persons in care.
POC Due Date: 05/13/2026
Plan of Correction
1
2
3
4
By the POC date date, Licensee agreed to E-mail to LPA the following documents on S5 (which are not already part of other POCs): LIC501 Personnel Record, LIC508 Criminal Record Statement, and Assisted Living Education new hire training certificates.
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and manager interviews, Licensee did not ensure that 2 of 5 staff (S4 and S5) records contained proof of current First Aid Training from persons qualified by such agencies as the American Red Cross. This posed a potential health risk to 5 of 5 residents (R1 through R5) in care.
POC Due Date: 05/13/2026
Plan of Correction
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2
3
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Licensee agreed to have S4 and S5 each complete First Aid Training. Licensee agreed to E-mail a copy of S4 and S5's new biennial first aid cards or certificates to LPA, by the POC due 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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2026


LIC809 (FAS) - (06/04)
Page: 9 of 15
Document Has Been Signed on 04/13/2026 09:12 PM - It Cannot Be Edited


Created By: Dang Nguyen On 04/13/2026 at 05:32 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: 04/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(9)
General Food Service Requirements
(9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, Licensee did not follow procedures which protect the safety and acceptability of food during food storage. This posed a potential health risk to 5 of 5 residents (R1 through R5) in care.
POC Due Date: 04/13/2026
Plan of Correction
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2
3
4
During today's visit, Licensee took corrective action regarding storage of eggs, celery, cabbage, and mayonnaise items which are normally stored cold/refrigerated. This action resolved the deficiency. Licensee agreed to retrain all current staff on what food items must be stored refrigerated (following the example of grocery stores) and to E-mail the training sign-in sheet to LPA by 05/13/2026.
Type B
Section Cited
CCR
87506(b)(9)
Resident Records
(b) Each resident's record shall contain at least the following information: (9) Name, address and telephone number of physician and dentist to be called in an emergency.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and manager interview: For 5 of 5 residents (R1 through R5), Licensee did not have in their record the name, address, and telephone number of a dentist to be called in an emergency. This posed a potential health risk to persons in care.
POC Due Date: 05/13/2026
Plan of Correction
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2
3
4
Licensee agreed to communicate with necessary parties to update the Facesheets for R1 through R5. If a resident does not have a preferred dentist, Licensee may list a default mobile professional who can be called for emergencies, until a preferred one is provided. Licensee agreed to E-mail the updated Facesheets for R1 through R5 to LPA, by the POC due 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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2026


LIC809 (FAS) - (06/04)
Page: 10 of 15
Document Has Been Signed on 04/13/2026 09:12 PM - It Cannot Be Edited


Created By: Dang Nguyen On 04/13/2026 at 05:32 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: 04/13/2026

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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4
Based on records review and manager interview, for 2 of 5 residents (R2 and R3), Licensee did not 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, prior to the resident's acceptance as a resident. This posed a potential health and safety risk to persons in care.
POC Due Date: 05/13/2026
Plan of Correction
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3
4
Licensee agreed to obtain a current and complete LIC602 Physician's Report, with negative Tuberculosis (TB) test result and/or chest X-ray, on both R2 and R3, and to E-mail copies of such to LPA, by the POC due date.
Type B
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on records review, Licensee did not ensure that the pre-admission medical assessment for 2 of 5 residents (R2 and R3) included the test results of an examination for communicable tuberculosis. This posted a potential health risk to persons in care.
POC Due Date: 05/13/2026
Plan of Correction
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2
3
4
Licensee agreed to obtain a current and complete LIC602 Physician's Report, with negative Tuberculosis (TB) test result and/or chest X-ray, on both R2 and R3, and to E-mail copies of such to LPA, by the POC due 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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2026


LIC809 (FAS) - (06/04)
Page: 11 of 15
Document Has Been Signed on 04/13/2026 09:12 PM - It Cannot Be Edited


Created By: Dang Nguyen On 04/13/2026 at 05:32 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: 04/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87467(a)
Resident Participation in Decisionmaking
(a) Prior to, or within two weeks of the resident's admission, 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, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review and manager interview, for 3 of 5 residents (R2, R3, and R4), Licensee did not within the last 12 months arrange a meeting with the resident and required individuals to review and revise the resident's written record of care. This posed a potential health risk to persons in care.
POC Due Date: 05/13/2026
Plan of Correction
1
2
3
4
For R2, R3, and R4 each, Licensee agreed to conduct a care conference with their responsible person (and visiting care agency personnel, if applicable) to review the resident's facility Plan of Care, updating it as needed. All parties to the meeting will sign. Licensee agreed to E-mail proof of care conference completion to LPA, by the POC due date. Going forward, Licensee agreed to facilitate such care conferences at least once every 12 months for each resident.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review and manager interview, Licensee did not conduct a disaster drill at least quarterly for each shift, and did not vary the type of emergency covered from quarter to quarter, taking into account different emergency scenarios. This posed a potential safety risk to 5 of 5 residents (R1 through R5) in care.
POC Due Date: 05/13/2026
Plan of Correction
1
2
3
4
Licensee agreed to conduct two (2) disaster drills (one in the daytime, and one at nightitme), and to E-mail proof of drill completion to LPA, by the POC due date. Going forward, Licensee agreed to drill each shift at least once per quarter, and to vary the type of disaster covered from one quarter to the next, and to keep written records of all drills.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2026


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Page: 12 of 15
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: 04/13/2026
NARRATIVE
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[CONTINUED FROM LIC 809] (Licensee explained that they believe R2 can turn and reposition themselves in bed; as part of the Plan of Correction, Licensee will contact R2’s physician to see if they would be willing to change R2’s status from bedridden to non-ambulatory. If the doctor does not concur, then Licensee will take legal steps to relocate R2 from the facility, which would bring the facility back in compliance with its prior approved fire clearance and facility license.) The facility’s license does not include endorsements for delayed-egress doors or secured perimeter, and neither of these were present.

R2 had a gastronomy tube, which is a Prohibited Health Condition in the RCFE setting. Although Licensee is themselves a Registered Nurse (RN), and although Licensee had documentation that facility direct care staff had received hands-on training from a licensed professional on on gastronomy care, Licensee had not yet applied for and received an approved Exception Request from CCLD to retain R2, with this Prohibited Health Condition. Per available LIC602 Physician’s Reports and manager interview: At least four (4) of the five (5) residents in care had either Dementia or Mild Cognitive Impairment (MCI), and their doctors determined that they should not have direct access to cleaning chemicals; all five (5) residents also required facility staff to store and administer their medications, for safety. LPA observed multiple prescription medications, belonging to two residents, left unsecured/unlocked on top of the kitchen counter. Additionally, there were cold-storage medications for a third resident in the facility’s refrigerator which were left unlocked. LPA was able to touch and move said medications without the staff’s awareness, before handing said medications to staff to immediately lock up. During today’s visit, Licensee produced a locking box for those medications which must be stored in the refrigerator.

Beneath the facility’s kitchen sink was an unlocked cabinet containing multiple cleaning chemicals. In the facility's laundry room, LPA observed cleaning chemicals stored next to non-perishable food; for example, a bottle of laundry detergent with a push-button spout was positioned directly above and inches away from some canned goods. During today’s visit, LPA directed staff to lock away all chemicals and to move the food to a separate storage area. The facility’s fire extinguisher was not serviced within the last twelve (12) months, as required. The smoke alarm device in Bedroom #4, which was present during the facility’s earlier fire clearance inspection, was removed/missing. During today’s visit, facility staff installed a replacement smoke alarm device in Bedroom #4. All other smoke alarms and the facility’s carbon monoxide detector were working. [CONTINUED ON LIC 809-C, 2 of 3]
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2026
LIC809 (FAS) - (06/04)
Page: 13 of 15
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: 04/13/2026
NARRATIVE
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[CONTINUED FROM LIC 809-C, 1 of 3] In the facility’s backyard: LPA observed two (2) gardening hand spades with metal blades and one (1) container of fertilizer, left out in the open, which LPA handed to staff to lock away. There was a collection of unused medical equipment (i.e., walkers, wheelchairs, and shower chairs) that had accumulated in the facility’s backyard, which LPA directed Licensee to relocate/discard, so to not interfere with residents'/visitors’ enjoyment of the premises.

Beyond this, the facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were working. Extra linens, hygiene supplies, and Personal Protective Equipment (PPE) were present. Night lights, flashlights, and facility telephone were all working. The First Aid Kit was complete with the required contents. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. There were no active fireplaces or open-faced heaters accessible to residents. No pools or bodies of water were observed on the premises. Per the Licensee, no firearms or ammunition are kept at the facility. Required licensing postings were observed in visible areas of the facility. Licensee presented proof of current business liability insurance.

The facility’s ambient internal temperature was complaint at 70 F. Hot water temperature at taps used by residents for grooming were initially too hot: Bathroom #1 Sink was 125.4 F and Bathroom #2 Sink was 128.1 F. (Regulation requires them to be between 105 F and 120 F). During today’s visit, adjustments were made to the facility’s water heater settings to bring these taps back into the complaint temperature range. Refrigerators and freezers used to preserve perishable food were compliant in temperature. There was at least two (2) days of perishable food, at least seven (7) days non-perishable food present, along with cooking/dining equipment and utensils. LPA observed the following food items (which ordinarily require cold-storage) being stored outside of the refrigerator: Celery, cabbage, eggs, and a prior-opened jar of mayonnaise. LPA provided corrective education to staff during today’s visit.

During a review of resident records, LPA observed, and manager interview confirmed: While R2 had a LIC602 Physician’s Report (“Medical Assessment”) that was filled out, it was not signed by R2’s physician, as required. Licensee did not have a completed LIC602 Physician’s Report for Resident #3 (R3), either. For R1, R3, and Resident #4 (R4), Licensee did not have written proof of a negative Tuberculosis (TB) test result or chest x-ray screening for the resident, which was required before move-in. [CONTINUED ON LIC 809-C, 3 of 3]
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2026
LIC809 (FAS) - (06/04)
Page: 14 of 15
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: 04/13/2026
NARRATIVE
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[CONTINUED FROM LIC 809-C, 2 of 3] For R1, R2, R3, R4, and Resident #5 (R5), Licensee did not have the name, address, and telephone number of the residents’ dentist to be called in the event of an emergency, as required. R3 had Diabetes (a “Restricted Health Condition” in the RCFE setting, per regulation), for which staff provided support and oversight of R3’s blood sugar testing (glucometer) and Insulin administration (flex pen). However, Licensee did not have written proof that five (5) of five (5) direct care staff [Staff #1 (S1) through Staff #5 (S5)] had received hands-on training from a licensed professional on Diabetes/Glucometer/Insulin, as was required before this care for R3 began. Licensee also did not have proof/documentation that they held a meeting/conference with the responsible person and other appropriate parties for R1, R3 and R4, for the purpose of reviewing and updating the resident’s written record of care / care plan within the last twelve (12) months, as was required.

Durning a review of staff records, LPA observed, and manager interview confirmed: For five (5) of five (5) direct care staff (S1 through S5) plus themselves [Staff #6 (S6)], Licensee did not maintain written proof of a completed LIC503 Health Screening (or equivalent job-related physical examination) with negative TB test result, signed by a doctor, as required before employment. S4 and S5 did not have proof of current First Aid Training, as required. Licensee did not have an employee file/record for S5, as required. Although Licensee performed two (2) disaster drills within the last year, this fell short of the frequency and variety of disaster drills described in regulation. Licensee also did not have written proof that they provided PPE training within the last twelve (12) months to S1 through S5, as required.

Eighteen (18) deficiencies were cited per California Code of Regulations, Title 22, and one (1) deficiency was cited per California Health and Safety Code (refer to the attached LIC 809-D pages). Plans of Correction were jointly developed with the Licensee. Since one of the deficiencies represents a violation of the facility’s prior approved fire clearance, an Immediate Civil Penalty of $500 was charged/assessed (refer to the LIC421-IM page). Since one of the deficiencies is a repeat violation within the last twelve (12) months, a repeat violation civil penalty of $250 was also charged/assessed (refer to the LIC421-FC page). LPA also issued Technical Assistance (TA) regarding periodically measuring and recording residents’ body weights and regarding refresher training for staff on California Mandated Reporting requirements (refer to the LIC9102-TA pages).

An exit interview was conducted with Licensee/Administrator Penelope Pankey, to whom a copy of this report, the LIC809-D pages, the LIC9102-TA pages, the LIC421-IM page, the LIC421-FC page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2026
LIC809 (FAS) - (06/04)
Page: 15 of 15