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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002279
Report Date: 11/07/2022
Date Signed: 11/07/2022 03:25:17 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/07/2022 03:25 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:SHANGRI-LA RCE #1FACILITY NUMBER:
306002279
ADMINISTRATOR:MYRIAM EGGERSFACILITY TYPE:
740
ADDRESS:4612 RHAPSODY DR.TELEPHONE:
(714) 377-3902
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92649
CAPACITY:6CENSUS: 2DATE:
11/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:19 PM
MET WITH:Myriam Eggers, Licensee/AdministratorTIME COMPLETED:
03:39 PM
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On today’s date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required annual inspection visit. LPA Quiroz was greeted and granted entry into the facility by caregiver. LPA Quiroz met with Licensee/Administrator Myriam Eggers and discussed purpose of the visit.

This facility is licensed to provide services to six (6) Non-Ambulatory residents and has a hospice waiver for two (2) residents. The facility is currently providing services to one (1) hospice resident.

L/AD Myriam Eggers has an Administrator Certificate with expiration date of 12/09/2022.

On today's date, LPA Quiroz reviewed 2 of 2 resident records. On or about 2:43pm, LPA Quiroz along with Caregiver and (L/AD) Eggers toured the inside and outside of the facility. There are two (2)residents in care and there are no active COVID-19 cases. During today's inspection visit, LPA Quiroz observed Resident 2 in living room area watching television with staff supervision and Resident 1 in her bedroom resting. Two of two residents present in the facility appeared to be clean and well taken care of. LPA Quiroz observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed to have ample soap/sanitizer and appeared clean. LPA Quiroz inspected residents’ bedrooms and appeared clean and sanitary. All bedrooms observed to have all required components. LPA Quiroz observed a check in station in the main entry of the facility. L/AD Myriam Eggers indicated facility will continue taking temperatures daily; and documenting results.

LPA Quiroz observed the emergency disaster and evacuation plan. Facility has back-up emergency food, water supply as well as PPE supplies. LPA Quiroz toured the outside of the facility and observed ample seating area with tables and chairs for resident’s enjoyment in backyard area.

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SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SHANGRI-LA RCE #1
FACILITY NUMBER: 306002279
VISIT DATE: 11/07/2022
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CONTINUED...

Facility has completed the LIC 808 Mitigation plan dated 1/24/2021. The LIC 808 Mitigation Plan was reviewed and approved during today's visit by LPA Quiroz . L/AD Myriam Eggers indicated "All staff and residents are fully vaccinated, have received all their boosters for COVID-19."

Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with L/AD Myriam Eggers and a copy of this report and LIC 811- Confidential names were provided at exit.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022
LIC809 (FAS) - (06/04)
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