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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002279
Report Date: 04/03/2023
Date Signed: 04/03/2023 02:41:21 PM


Document Has Been Signed on 04/03/2023 02:41 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: 0DATE:
04/03/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Myriam EggersTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a facility closure inspection. LPA was greeted and granted entry by Administrator (AD) Myriam Eggers and the purpose of the inspection was discussed.

Licensee, whom is also AD, informed Community Care Licensing (CCL) of their intent to close the facility on 3/15/23, due to having no residents in the home and deciding to sell the property.

During the inspection LPA Gutierrez verified that there were no residents in care. AD surrendered their facility license to LPA. An exit interview was conducted, a copy of this report and closure letter was provided to AD.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2023
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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