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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490107833
Report Date: 09/03/2021
Date Signed: 09/03/2021 03:47:08 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:FLORA SHANGRILAFACILITY NUMBER:
490107833
ADMINISTRATOR:SALONGA, LAILAFACILITY TYPE:
740
ADDRESS:3052 COFFEY LANETELEPHONE:
(707) 578-3162
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:6CENSUS: 5DATE:
09/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Laila Salonga-AdministratorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Alviso, arrived unannounced to conduct an 1 YR Required inspection and met with Administrator Laila Salonga, and Licensee Flora Salonga The inspection is focused on the Infection Control procedures and practices of this facility.

Facility has an approved dementia plan of operation. There is an approved hospice waiver for one (1) resident. Mitigation plan was approved by the Department on 2/5/21. Fire clearance is approved for six (6) non-ambulatory. There were five (5) residents in care at the facility during this inspection. All visitors, essential visitors, and staff are screened upon entry; Temperatures are taken, and screening questions are to be answered before being allowed to remain in the facility, all information is logged. Residents are screened twice daily, and observed for any changes, all information is logged. The facility was at a comfortable temperature with all exits free from obstruction. Toxins are stored in locked cabinets. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Medications were stored locked making them inaccessible to residents in care. All bathrooms had grab bars, and non-slip mat/flooring for bathing as needed. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment(PPE). Administrator stated that staff are to wear masks in the facility, and when providing care services to the residents in and out of the facility. Administrator and staff had masks on during the LPA's inspection.

No deficiencies found in the areas inspected.
Exit interview conducted with the Administrator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021
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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