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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306002279
Report Date:
12/29/2021
Date Signed:
12/29/2021 05:35:46 PM
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
SHANGRI-LA RCE #1
FACILITY NUMBER:
306002279
ADMINISTRATOR:
MYRIAM EGGERS
FACILITY TYPE:
740
ADDRESS:
4612 RHAPSODY DR.
TELEPHONE:
(714) 377-3902
CITY:
HUNTINGTON BEACH
STATE:
CA
ZIP CODE:
92649
CAPACITY:
6
CENSUS:
4
DATE:
12/29/2021
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
11:55 AM
MET WITH:
Licensee Myriam Eggers
TIME COMPLETED:
02:07 PM
NARRATIVE
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Licensing Program Analyst (LPA) Shobhana Frank conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and granted entry into the facility by Licensee Myriam Eggers and explained the reason for the visit.
LPA Frank toured the facility. There are four residents residing in the facility and no active COVID-19 cases. LPA observed four residents on site. All residents appeared clean and well taken care of. LPA observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed had ample soap/ sanitizer and appeared clean. Resident bedrooms appeared clean and sanitary and had all required components. Facility is taking residents temperatures and documenting results.
LPA observed the emergency disaster and evacuation plans. Facility has back-up emergency food and water supply as well as PPE supplies. Facility has completed the LIC 808 Mitigation Plan.
No citations noted during today's visit. Exit interview conducted and a copy of this report was provided.
SUPERVISOR'S NAME:
Marina Stanic
TELEPHONE:
(714) 703-2851
LICENSING EVALUATOR NAME:
Shobhana Frank
TELEPHONE:
(714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE:
12/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/29/2021
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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