216803917-4-30-2026-21-AS-ALOA-DTMTET-20260430144028

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803917
Report Date: 04/30/2026
Date Signed: 04/30/2026 02:40:43 PM

Document Has Been Signed on 04/30/2026 02:40 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 HOME		FACILITY NUMBER:	216803917
ADMINISTRATOR/ DIRECTOR:	GONGORA,JASMIN		FACILITY TYPE:	737
ADDRESS:	200 DARYL AVENUE		TELEPHONE:	(415) 493-6622
CITY:	NOVATO	STATE: CA	ZIP CODE:	94947
CAPACITY: 4		CENSUS: 3	DATE:	04/30/2026
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:25 AM
MET WITH:	Lead Staff, Yadira Rodriguez		TIME VISIT/ INSPECTION COMPLETED:	02:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	04/30/2026; Licensing Program Analyst (LPA) Loera arrived unannounced to conduct a case management visit and met with Lead Staff, Yadira Rodriguez. There are currently three clients in care, which all three were present during visit. Administrator, Jasmin Gongora was available via phone. LPA observed areas of concern addressed in the Department of Developmental Services (DDS) onsite report dated 04/15/2026. Areas addressed were observed to be incompliance with Title 22 Regulations. The areas of concern noted by DDS are regarding regulations Buildings and Grounds (80087), Furniture and Fixtures (80088), and Health Related Services (80075). LPA toured the facility and observed the kitchen faucet to be in working order, garage refrigerator's door to be in good repair, door handle leading to the backyard to be in good repair, emergency food supplies to be in a separate locked cabinet from cans of paint, and three out of three client MARs records for PRNs to be completely filled out. LPA observed the front garden area to have pvc piping that was not being used and not connected to any water source and does not affect the facility in anyway. Piping was observed to be pushed against the the facilities wall being obstruction free. LPA observed the front garden to be covered with bark with some exposed black tarp in certain areas, which is cosmetic. LPA observed a drawer underneath the oven to not shut fully but is still functional. LPA observed window screens missing in two out of two bathrooms, per conversation with lead staff they have a client (C1) who will push out window screens if they replace them and could trigger the clients behavioral as they are OCD and likes things to be a certain way. LPA observed one bathroom toilet to have a missing tank lid, per conversation with lead staff, a client (C2) had a behavior on 02/01/2026. Community Care Licensing (CCL) received a special incident report (SIR) on 02/03/2026 regarding C2 throwing the bathroom tank outside. The facility replaced the tank lid and then C1 broke the lid on 4/7/2026. Per conversation with lead staff they had a work order put in for a new toilet lid on 4/7/2026 which is still pending. LPA observed the bathroom toilet to still be functional. continued on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Anthony Loera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026

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: 04/30/2026

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LPA observed the vanity in one of the bathrooms to have a wooden leg that is crooked but does not affect the vanity not being stable. LPA observed the vanity to have paint peeling exposing the wood underneath, potentially cause by water damage but unsure. The bathroom vanity is functional and has cosmetic damage. LPA observed the vanity in the bathroom to have two missing knobs for two separate drawers. One drawer had a missing knob on the left side of the vanity but the drawer stretches across the vanity and has a knob located on the right side that still lets the drawer open with no issues. The vanity has a small drawer with a missing knob on the top left side and was found to still be functional. LPA observed the hallway to have an area where the flooring was warped but was not a trip hazard. Medication box was found to be locked and secured in the medication cabinet located in the kitchen. LPA observed two out of the three windows in the living room to have broken glass with glass shards around the frame and the window blinds for one window to be ripped, per conversation with lead staff, client (C3) had a behavior on 4/14/2026 and shattered the windows, facility then submitted a work order on 4/14/2026 and heard back on 4/19/2026 to take measurements for the windows and notified the facility it will take time to replace it since the windows are custom size. Community Care Licensing received an SIR on 04/20/2026 regarding the incident.

Lead staff stated when a client has a behavior and begins breaking items around the facility, their main goal is to bring the client back to baseline to ensure their safety. Once a client has been brought back to baseline, any damage that has been done to the facility, staff will then begin walking around taking pictures and submit a work order to their Housing Development Organization, Joshua Tree. Facility communicates with Joshua Tree via whats app for items that are in need of repair.

No deficiencies were cited today. Copy of report was provided to Lead Staff.

NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Anthony Loera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026

LIC809 (FAS) - (06/04)

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