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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603686
Report Date: 09/04/2025
Date Signed: 09/04/2025 01:10:04 PM

Document Has Been Signed on 09/04/2025 01:10 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
MONTEREY PARK ASC, 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:
09/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Rocio Collado (Administrator)TIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced annual inspection visit. LPA was allowed entry by Maria Teresa Cerino. LPA spoke to Rocio Collado via telephone and discussed the purpose of today’s visit.

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 currently approved for (12) AMBULATORY residents only. Per Ms. Collado, this facility will only be able to accommodate up to (9) residents and not (12) residents. This facility has not admitted any residents since becoming licensed.

The following was discussed during the telephone call with Ms. Collado:

  • Change in capacity- Ms. Collado was instructed to submit a new LIC 200/Application, facility sketch and a check to CDSS for the request of change in capacity. The new LIC 200 and facility sketch is to identify/reflect the total number of beds (including non-ambulatory).

  • Request for non-ambulatory- Per Ms. Collado, there is an inspection pending with the Fire Department to move forward with this request. Ms. Collado will provide updates to LPA. Additionally, LPA briefly discussed dementia plan as potential residents with this diagnoses are considered to be non-ambulatory. This facility does not have a dementia plan in place.


Refer to LIC 809C for the continuation of this report.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SHANGRILA HEALTHCARE INC
FACILITY NUMBER: 198603686
VISIT DATE: 09/04/2025
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  • Overdue licensing fees- LPA provided Ms. Collado the information (including PIN) to pay fees on-line today as they are due today. A copy of the facility transaction with PIN information was left at this facility and also sent via text to Ms. Collado.

  • Liability Insurance: LPA requested a copy of the current insurance coverage.

  • Guardian Portal- LPA discussed with Ms. Collado the requirement of having all staff finger print cleared and associated to this facility prior to accepting the first resident.

  • Self-Assessment Guide (Residential Care Facility for the Elderly)- LPA discussed this tool and provided a copy. LPA also sent a picture of this document to Ms. Collado via text.


LPA utilized the Compliance and Regulatory Enforcement (CARE) tool:
Infection Control: Facility has an Infection Control Policy in place.
Operational Requirements: This facility has not admitted any residents since becoming licensed.
Physical Plant & Environment Safety: LPA toured facility grounds. Fire smoke alarms and carbon monoxide detector observed. The fire extinguishers observed and appeared to be full. Bedrooms have the required furniture. Bathrooms have non-skid surfaces and grab bars. Hot water temperature (156.4* in bathroom near bedroom #5 and 152.2 the other bathrooms (Advisor Note- Technical Violation issued as there are no residents residing at this facility.
Staffing: This facility has not admitted any residents since becoming licensed.
Personnel Records-Training: This facility has not admitted any residents since becoming licensed.
Resident Rights-Information: This facility has not admitted any residents since becoming licensed.
Planned Activities: This facility has not admitted any residents since becoming licensed.
Food Service: This facility has not admitted any residents since becoming licensed.
Resident Records-Incident Reports:This facility has not admitted any residents since becoming licensed.
Disaster Preparedness: Facility has a disaster preparedness plan in place.
Health Related Services/Incidental Medical Services: This facility has not admitted any residents since becoming licensed.

Exit interview conducted, copy of appeal rights and this report was provided to Maria Teresa Cerino.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC809 (FAS) - (06/04)
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