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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603686
Report Date: 06/13/2024
Date Signed: 06/13/2024 02:03:10 PM

Document Has Been Signed on 06/13/2024 02:03 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SHANGRILA HEALTHCARE INCFACILITY NUMBER:
198603686
ADMINISTRATOR/
DIRECTOR:		COLLADO, ROCIOFACILITY TYPE:
740
ADDRESS:692 E PHILLIPS BLVD BLDG ATELEPHONE:
(626) 322-5546
CITY:POMONASTATE: CAZIP CODE:
91766
CAPACITY: 12CENSUS: 0DATE:
06/13/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Rocio Collado/Applicant TIME VISIT/
INSPECTION COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted a scheduled pre-licensing visit. LPA met with Rocio Collado (Applicant/Administrator), Anna Aldiano (Assistant Administrator) and Lucio Collado.

This facility consists of (6) bedrooms, (1) staff/employee room, (3) full bathrooms, (1) ½ bathroom, utility room (laundry), living room, dining room, kitchen. This facility is approved for (12) AMBULATORY residents only. During this visit, LPA conducted a facility tour and conducted Component III.

The following was observed/inspected:

  • Smoke detectors operate properly.
  • Carbon monoxide detector was tested and operable.
  • Fire extinguishers located in the kitchen and near the dining room.
  • Cleaning solutions (under kitchen sink) and sharps are locked in the kitchen.
  • Building and grounds are free from hazards.
  • Beds have the required linen/supplies.
  • Bedrooms are large enough to allow for easy passage between and comfortable for usage of beds and other required items of furniture.
  • There are enough bath towels, hand towels and wash cloths for all residents.
  • There are sufficient amount of linens available to permit weekly changing to ensure use of clean linens at all times by residents.
  • Facility has a washer and dryer that are fully operational located inside the utility room.
  • Pantry's cupboards, freezers, stoves, microwaves, refrigerator and counters are clean.
  • Two-day supply of perishables available, seven day supply of non-perishable available.
  • Pesticides and other toxic substances are stored and locked away from food supply.
  • Staff and Resident files (including resident medications) will be locked inside the staff/employee room.
Refer to LIC 809C for the continuation of this report.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SHANGRILA HEALTHCARE INC
FACILITY NUMBER: 198603686
VISIT DATE: 06/13/2024
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  • Physical plant is in good repair.
  • Building and grounds are free from hazards.
  • Window screens are in good repair and windows/curtains/blinds are in good repair and operate properly.
  • Refrigerator, stove, telephone, sinks, tubs, toilets and showers operate properly.
  • Hot water temperature measured within regulation (115.5* to 117.5*)

Pending:
  • Surveillance Cameras: Applicant to follow up with Centralized Applicant Bureau (CAB) for guidance.
  • Hospice Waiver: Applicant to follow up with Centralized Applicant Bureau (CAB) for status.
  • Liability Insurance (H&S Code 1569.605): Applicant has not yet purchased as license has not been issued.
  • Facility Sketch LIC 999: to be updated accordingly (staff/employee room to be reflected).
  • Planned Activities/87219(d): Activity schedule missing.
  • Telephone line/87311: Per Applicant, still awaiting for provider to connect this service.
  • First Aid Manual/87465(a)(9)(A): Manual has a copyright year of 2018. Applicant to obtain most current copy.
  • First Aid Kit/Thermometer/87465(a)(9)(F): Kit is missing the thermometer.
  • Grab bars/87303(e)(4): All full bathrooms are missing grab bar near the toilets.

Exit interview conducted, copy of report provided to Rocio Collado/Applicant.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC809 (FAS) - (06/04)
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