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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803917
Report Date: 01/27/2026
Date Signed: 01/27/2026 01:20:26 PM

Document Has Been Signed on 01/27/2026 01:20 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:SHALAMO HOMEFACILITY NUMBER:
216803917
ADMINISTRATOR/
DIRECTOR:		GONGORA,JASMINFACILITY TYPE:
737
ADDRESS:200 DARYL AVENUETELEPHONE:
(415) 493-6622
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 4CENSUS: 4DATE:
01/27/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator, Jasmin GongoraTIME VISIT/
INSPECTION COMPLETED:
01:35 PM
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01/27/2026, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. There are currently four clients in care. Facility approved/cleared for four ambulatory. Facility has delayed egress approved. During arrival, three clients were present and one client was attending day program. LPA was greeted by staff member. Administrator, Jasmin Gongora arrived shortly after.

LPA and Administrator toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Emergency food supplies are located in the garage.

All rooms were furnished per regulation. Extra hygiene products and linens were available. Water temperature in sinks were measured and found to be within the range of 105 to 120 degrees F. Fire extinguishers were last inspected November 2025. Facility has smoke/carbon monoxide detectors located throughout the facility that were tested and operational. Cabinets containing cleaning supplies were locked. Sharps were kept in a locked box located in a locked drawer in the kitchen. Medications were found to be centrally stored. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record.

LPA conducted a review of three client records. One out of three clients are missing a physicians report, per conversation with administrator they have an appointment next week and will receive the required physicians form. LPA conducted review of three staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.

continued on LIC809
NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Anthony Loera
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2026
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: SHALAMO HOME
FACILITY NUMBER: 216803917
VISIT DATE: 01/27/2026
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Facilities last emergency/fire drill was conducted on 12/15/2025.

While conducting annual inspection, LPA followed up on a special incident report (SIR) that was submitted to community care licensing (CCL) on 01/20/2026. Incident report states 01/16/2026, "around 6pm client (C1) was in the living room hanging out with one of their roommates. C1 became upset over a comment their roommate made and they got into a verbal argument. Staff (S1) was able to verbally redirect C1 outside so they could talk. C1 agreed but once walking outside C1 climbed the fence and jumped over it. S1 went out through the front gate and began following C1. C1 began running around the neighborhood while S1 followed closely. C1 continued running around the neighborhood attempting to hide from S1 and evading from S1 for an hour. At 7pm C1 approached S1 and asked to talk. C1 began yelling and cursing. S1 asked C1 to lower their voice and be respectful to which C1 agreed. After talking for about 20 minutes C1 agreed to walk back home. S1 and C1 walked back home and arrived around 7:30pm."

Per conversation with administrator the one hour when C1 was evading from S1, C1 was always in line of sight.

No deficiencies cited during today's inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 02/27/2026:

LIC500- Personnel Report
LIC308- Designation of Responsibility
Updated Liability Insurance
Current Lease

Exit interview conducted with Administrator and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Anthony Loera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2026
LIC809 (FAS) - (06/04)
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