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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306002279
Report Date: 12/22/2022
Date Signed: 12/22/2022 10:23:57 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/14/2022 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20221214162537
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: 1DATE:
12/22/2022
UNANNOUNCEDTIME BEGAN:
10:06 AM
MET WITH:Miriam EggersTIME COMPLETED:
10:43 AM
ALLEGATION(S):
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9
Facility failed to report incident within seven days of the occurrence
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility by Administrator Eggers and explained the reason for the visit.
During the course of the investigation, LPA toured resident room, interviewed staff and witness as well as reviewed and obtained pertinent documentation such as physician report and incident report. Regarding the allegation that facility failed to report incident within seven days of the occurrence, the investigation revealed the following: Facility submitted the written incident report on 12/11/2022 to LPA Frank's email. LPA Frank is no longer employed at Community Care Licensing. Facility forwarded incident report to LPA Lyman and time stamp confirms submittal within 7 seven days. Therefore the allegation is deemed UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was left at the facility.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/14/2022 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20221214162537

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: 1DATE:
12/22/2022
UNANNOUNCEDTIME BEGAN:
10:06 AM
MET WITH:Miriam EggersTIME COMPLETED:
10:43 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to provide care and supervision resulting in injury
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility by Administrator Eggers and explained the reason for the visit.
During the course of the investigation, LPA toured resident room, interviewed staff and witness as well as reviewed and obtained pertinent documentation such as physician report. Regarding the allegation that facility failed to provide care and supervision resulting in injury, the investigation revealed the following: On 12/05/2022, Resident 1(R1) was being assisted to bed by Staff 1(S1). S1 stepped a few feet away to get a sweater and the resident attempted to stand up out of the wheelchair in that moment and fell forward. 911 was called and resident was sent to the hospital and returned same day with a laceration on the head and a concussion. Three out of three witnesses interviewed indicate the resident attempts to get out of wheelchair but had not had any falling occurrences lately. Witnesses confirm resident had fallen when first admitted into the facility three years ago but no occurrences in recent history. Facility has implemented measures to prevent falls including ensuring foot pedals are on at all times and CONTINUED ON LIC 9099 C DATED 12/22/2022
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20221214162537
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/22/2022
NARRATIVE
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ensuring resident is constantly monitored. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3