490107833-8-18-2022-21-AS-DALO-CHEVAS-20220818161627

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 490107833
Report Date: 08/18/2022
Date Signed: 08/18/2022 04:16:40 PM

Document Has Been Signed on 08/18/2022 04:16 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	FLORA SHANGRILA		FACILITY NUMBER:	490107833
ADMINISTRATOR:	SALONGA, LAILA		FACILITY TYPE:	740
ADDRESS:	3052 COFFEY LANE		TELEPHONE:	(707) 578-3162
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	6	CENSUS: 4	DATE:	08/18/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Laila Salonga-Administrator		TIME COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Alviso, arrived unannounced to conduct an Required 1-Year inspection and met with Administrator Laila 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 (4) residents in care at the facility during this inspection. Licensee Flora Salonga was the staff person who met with the LPA upon LPA's arrival. Licensee was not wearing a mask as required; Licensee didn't screen the LPA as required. The LPA observed that there was no screening area set up and no screening items , no thermometer, no log book with sign in and screening questions as needed and required. Licensee stated to the LPA that they would go wake up the Administrator who had worked last night. Administrator Laila Salonga told the LPA that they have another job and they work nights. LPA toured the facility with the Administrator. Exits were unobstructed. Fire extinguishers were serviced and tagged as required-dated 9/28/21. Administrator stated her understanding of the need to ensure the extinguishers are serviced before expiration of current tags date. Food supply was sufficient. PPE supply was sufficient. Cleaners and hygiene products were sufficient. The staff (S2) didn't screen the LPA (visitors) as required, and the staff(S2) was observed to not be wearing a mask as required, these deficiencies will be cited, regulation 87405(d)(2) Administrator Qualifications and duties, and 87468.1(a)(2) Personal Rights of Residents in All Facilities-see LIC809D. ontinued on LIC809C...

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022

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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: FLORA SHANGRILA	FACILITY NUMBER: 490107833
	VISIT DATE: 08/18/2022

NARRATIVE

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LPA observed the resident hallway bathroom to need cleaning, the sink was very dirty, and the faucet knobs were dirty, and the tub needed cleaning and the faucet knobs put back on. The kitchen counter tops were dirty with crumbs and food spills, the appliances were all dirty and in need of cleaning. Floors in both the bathroom and the kitchen needed to be clean from dirt and and/or crumbs and spills. LPA obtained pictures. This deficiency will be cited, Maintenance and Operation 87303(a)(1)-see LIC809D.
LPA observed medications in a residents room, prescription and over the counter; the staff stated they handle resident medications and don't know the resident had these medications. LPA discussed with the Administrator that all prescribed medications and over the counter medications/supplements are to be centrally stored/secured per regulations. This deficiency will be cited, Incidental Medical and Dental Care 87465(h)(2), see LIC809D.
LPA observed a bag of frozen chicken outside in the front of the facility on the front porch area, it was put there to defrost. This is an unsafe method to defrost food. This deficiency will be cited, General Food Service Requirements 87555(b)(9), see LIC809D.
LPA observed that a residents room smelled strongly of urine; LPA observed that the resident's commode was full of urine and feces, and the resident is to receive incontinent care as part of their needs/care plan. Administrator stated that the resident has accidents and also uses the commode, staff stated they clean the room. LPA discussed regulation regarding managed incontinence needs and care. This deficiency will be cited, Managed Incontinence 87625(b)(3), see LIC809D.

LPA discussed concerns regarding the facility having an Administrator able to work at the facility as required, sufficient staffing to meet needs of residents, and the facility operations at all times. The LPA will set up a meeting with the Licensing Manager and Regional Manager to meet with the Licensee and Administrator to address the deficiencies cited today, and the concerns of the operation of this facility license. LPA will contact the Licensee Flora Salonga, and the Administrator on record Laila Salonga to set the meeting date and time.
Deficiencies cited from the California Code of Regulations, Title 22, and/or California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.
Appeal rights were provided.
Exit interview conducted with the Administrator and the Licensee.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022

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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: FLORA SHANGRILA	FACILITY NUMBER: 490107833
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87405(d)(2)

Administrator Qualifications and Duties- 87405(d)(2) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply: (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by: LPA's observation by S2 not screening the LPA upon entry and/or after the LPA was in the facility by S2.
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation and interview with S2, the licensee did not comply with the section cited above in [1] out of [3] staff persons, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/19/2022
	Plan of Correction
1 2 3 4	Licensee to ensure that all Visitors & Staff are screened as required before entering and/or being allowed in the facility. Submit how the facility will be in compliance and ensure that all visitors and staff are screened as required, helping ensure health and safety of residents in care and being in compliance with regulation requirements. POC due 8/19/22

Type A

Section Cited

CCR

87468.1(a)(2)

87468.1(a)(2) Personal Rights of Residents in All Facilities a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: LPA observed S2 not wearing a mask in the facility as required by all staff.
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation and interview with S2, the licensee did not comply with the section cited above in 1 out of 3 staff persons, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/19/2022
	Plan of Correction
1 2 3 4	Licensee to ensure all staff are in compliance with the mask requirement, and ensure compliance with infection control plan; Licensee to ensure that staff anre wearing appropriate masks as required at all times. Submit plan of how the facilitywill ensure compliance with this regulation. POC due 8/19/22.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/18/2022 04:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: FLORA SHANGRILA	FACILITY NUMBER: 490107833
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87625(b)(3)

Managed Incontinence 87625(b)(3) (b)In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by: Resident's room R1 when inspected by the LPA. The room smelled strongly of urine, and the commode was also full of urine and feces. R1 is incontinent as needs incontinent services/assistance by staff.
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation and interview with Administrator, the licensee did not comply with the section cited above in one resident who is incontinent, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/19/2022
	Plan of Correction
1 2 3 4	Licensee to ensure that staff clean the residents room and disinfect the room as required to help ensure the facility is and residents room is free from urine odors, including feces odors. Staff are to ensure the resident is receiving all incontinent care services per regulations. Submit plan on how the resident's room was cleaned, and how the facility will ensure the residents room is mainatined to be clean and free of urine odors per regulations. POC due 8/19/22.

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care 87465(h)(2) (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: LPA observed medications in Residents room(R2), Advil, neosporin, a prescription medication, and other over the counter medications.
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation], the licensee did not comply with the section cited above in ensuring all medications, including over the counter medications are locked and inaccessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/19/2022
	Plan of Correction
1 2 3 4	Licensee to ensure all medications, including over the counter medications and supplements, are locked and inaccessible to residents at all times Submit plan on how the facility will ensure all medications are centrally stored per regulations, and how the facility will enure future compliance with this regulation. POC due 8/19/22

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/18/2022 04:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: FLORA SHANGRILA	FACILITY NUMBER: 490107833
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)(1)

Maintenance and Operation 87303(a)(1) Maintenance and Operation 87303 (a)(1) (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1)Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by:LPA observed the hallway bathroom and the kitchen to need cleaning; The bathroom sink and bathtub need to be cleaned and tub fixtures need to be put back on. The kitchen cabinets, counters, and appliances were all dirty and stained with food/liquid splashes, and the counters were dirty and had food spills and crumbs on them. The stove was dirty and needed cleaning, stove top and doors.
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation when touring facility with the Administrator, the licensee did not comply with the section cited above in maintaining the facility in good repair and keeping the facility clean and sanitary, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/26/2022
	Plan of Correction
1 2 3 4	Licensee to ensure the facility is cleaned and disinfected, and the bathroom is cleaned and tub fixtures re-installed, also clean all kitchen appliances and countertops, and floors in bathrooms and in the kitchen. Submit how the bathroom and kitchen were cleaned and brought into compliance and also plan on how the facility will maintain the facility per regulations. Submit plans and pictures of all areas/appliances cleaned. POC due 8/26/22.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022

LIC809 (FAS) - (06/04)

Page: 5 of 6

Document Has Been Signed on 08/18/2022 04:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: FLORA SHANGRILA	FACILITY NUMBER: 490107833
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(9)

General Food Service Requirements 87555(b)(9) b)The following food service requirements shall apply: (9)Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service This requirement is not met as evidenced by: LPA observed a bag of frozen chicken set outside on the front porch to defrost in the open.
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, the licensee did not comply with the section cited above in proper handling of food and ensuring compliance with regulation, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/19/2022
	Plan of Correction
1 2 3 4	Licensee to ensure that all staff handle and store food as required by regulations; Licensee to ensure that food is defrosted in a safe manner to ensure food iis safe for residents to consume . Submit plan on how the facility will ensure all food handling is in complaince with regulation,, including defrosting of food items, ensuring the safety of the food served to residents in care at all times. POC due 8/19/22.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022

LIC809 (FAS) - (06/04)

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