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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490107833
Report Date: 08/29/2023
Date Signed: 08/29/2023 06:50:42 PM


Document Has Been Signed on 08/29/2023 06:50 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 SHANGRILAFACILITY NUMBER:
490107833
ADMINISTRATOR:SALONGA, LAILAFACILITY TYPE:
740
ADDRESS:3052 COFFEY LANETELEPHONE:
(707) 578-3162
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:6CENSUS: 5DATE:
08/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Flora Salonga-LicenseeTIME COMPLETED:
07:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alviso, arrived unannounced to conduct a Required- 1 Year inspection, on 8/29/23 at approximately 9:30am, and was let in the facility by caregiver Justina. LPA observed the licensee, Flora Salonga, sitting in the living room.

Facility has an approved dementia plan of operation. There is an approved hospice waiver for one (1) resident. Fire clearance is approved for six (6) non-ambulatory. There were five (5) residents in care at the facility during this inspection.

Caregiver Justina told the LPA there were five residents, and they also help the Licensee as needed. LPA observed after touring the facility with the caregiver that there were five residents in care.

Licensee stated to the LPA that they would like to quit and close the facility due to personal reasons. The LPA discussed closure of the facility with Flora Salonga; Flora is the only Licensee on the facility license.

Facility has an approved dementia plan of operation. There is an approved hospice waiver for one (1) resident. Fire clearance is approved for six (6) non-ambulatory. There were five (5) residents in care at the facility during this inspection.

The LPA toured the facility with the caregiver Justina. The exits were unobstructed. Fire extinguishers, two(2), were serviced and tagged as required. Bathrooms were cleaned, resident bedrooms and facility common areas had sufficient lighting. Sufficient furnishings for resident use.

The LPA reviewed five(5) resident files. All staff have required criminal record clearance.

Continued on LIC809C....
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023
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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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: 08/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(b)
Other Provisions
(b) At least one administrator, facility manager, or designated substitute who is at least 21 years of age and has qualifications adequate to be responsible and accountable for the management and administration of the facility pursuant to Title 22 of the California Code of Regulations shall be on the premises 24 hours per day. The designated substitute may be a direct care staff member who shall not be required to meet the educational, certification, or training requirements of an administrator. The designated substitute shall meet qualifications that include, but are not limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA’s interviews and record reviews, There is no facility Administrator. LPA interviewed former Administrator LS, who stated they are not the Administrator since obtaining a full time job last year at Kaiser, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2023
Plan of Correction
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2
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4
Licensee to ensure there is a staff on-site on all shifts that meets requirements of H&S Code 1569.618(b). Submit an updated LIC 500 showing sufficient staffing; Submit a plan of correction no later than 8/30/23.
Type A
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on Per LPA’s file review and interviews, the facility lacks required liability insurance; S2 stated they don't have the liability insurance and they can't buy it, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2023
Plan of Correction
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2
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Licensee to ensure the facility obtains liability insurance as required; Submit a copy of liability insurance no later than 9/4/2023. Submit plan of correction by 8/30/23.
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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023
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: 08/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on LPA's interviews with staff, and record reviews, S1, S2, and S3 lacked current first aid certification, the licensee did not comply with the section cited above in [3] out of [3] staff records, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2023
Plan of Correction
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Licensee to ensure staff have CPR, and first aid. Submit a copy, by 9/4/23, of CPR certification for all staff that will be on shift by themselves, as there must be one staff on every shift with CPR per H&S Code. Submit plan of correction by 8/30/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023
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: 08/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(a)
Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record reviews, and interviews, the facility has no qualified Administrator, and/or sufficient caregivers on staffing schedule. The one hired caregiver (S3) works from 7:45am to 12pm, leaves the facility, and returns at 3pm to work till 6pm. There are no other caregivers but S3, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2023
Plan of Correction
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Licensee to ensure there is required staffing and sufficient staffing on-site to provide services to the residents, and ensure the plan of operation is running in compliance with regulations/H&S Code. Submit a staffing plan, and an updated personnel roster, LIC500. Submit how the facility will ensure compliance with this regulation. POC due 8/30/2023.

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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023
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: 08/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(a)
Other Provisions
(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Per LPA's interviews, and record reviews, Licensee has no Administrator, and has no qualified staff as a designee; S3 has no required training. S3 works 7:45am to 12pm and 3pm to 6pm. S1 & S2 lack First Aid & CPR certification, and no proof of required annual training, the licensee did not comply with the section cited above in, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2023
Plan of Correction
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Licensee to hire a qualified Administrator for the facility as required by regulations/H&S, ensure there are qualified staff trained as required to be on-site, responsible for the operation of the facility when the Administrator is temporarily absent. Submit plan of correction by 8/30/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023
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: 08/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Per LPA's record reviews, and interviews, S3 has no required initial training and/or annual training as required by H&S 1569.625(b)(1); Per LPA record reviews, Staff S1 & S2 lack annual required training, the licensee did not comply with the section cited above in [3] out of [3] staff which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2023
Plan of Correction
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4
Licensee to ensure that all staff have required initial training when hired, and required annual training per H&S Code. Submit plan of correction in all staff obtaining required trainings, initial 40 hour required training for S3, and annual training for S1 & S2. Proof of training to be submitted by 9/30/23. Submit Plan Of Correction by 8/30/23.

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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023
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: 08/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's record reviews, S1, S2, and S3 all lack proof of current first aid certification, the licensee did not comply with the section cited above in [3) out of [3] staff, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2023
Plan of Correction
1
2
3
4
Licensee to ensure staff obtain required first aid. Submit a copy of first aid certification by 9/4/23. Submit plan of correction by 8/30/23.
Type A
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Per LPA's interviews and record reviews, S3 lacks required initial medication training and annual required medication training; I4 who is not a staff or the Administrator also assists residents with medications. I4 does not have required training to handle medications, per file reviews, S1 & S2 lack medication training per file reviews, and LPA interviews, the licensee did not comply with the section cited above in [3] out of [3] staff and a former staff I4 who lives on the property, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2023
Plan of Correction
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2
3
4
Licensee to ensure all staff that handle medications obtain required H&S Code Required Medication training, initial and annual training. Submit a copy/proof of staff that have obtained medication training meeting 1569.69(a)(2) by 9/11/23. Submit plan of correction by 8/30/23.
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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023
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: 08/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's record reviews, S3 lacked a health screening, LIC503 form, including a TB test and TB results, the licensee did not comply with the section cited above in [1] out of [3] staff records, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/08/2023
Plan of Correction
1
2
3
4
Licensee to ensure staff (S3) obtains a health screening including a TB test/results as required; Submit a copy of the staffs (S3) health screening by POC due date of 9/8/23.

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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023
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: 08/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(b)(3)
Other Provisions
(b) At least one administrator, facility manager, or designated substitute who is at least 21 years of age and has qualifications adequate to be responsible and accountable for the management and administration of the facility pursuant to Title 22 of the California Code of Regulations shall be on the premises 24 hours per day. The designated substitute may be a direct care staff member who shall not be required to meet the educational, certification, or training requirements of an administrator. The designated substitute shall meet qualifications that include, but are not limited to, all of the following: (3) Training to effectively interact with emergency personnel in the event of an emergency call, including an ability to provide a resident’s medical records to emergency responders.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's record reviews, and interviews, the licensee has no Administrator and/or qualified staff to be the designated substitute as required by H&S 1569.618(b)(3), the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2023
Plan of Correction
1
2
3
4
Licensee to ensure there is a qualified and certified Administrator on facility premises as required, including having qualifed staff trained, and able to manage and administrate as required by H&S Code. Submit your staffing plan, also an updated LIC500 personnel report. Plan of correction due by 9/15/2023.

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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023
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: 08/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87415(a)
Night Supervision
(a) The following persons providing night supervision from 10:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures, shall be trained in first aid as required in Section 87465, Incidental Medical and Dental Care Services, and shall be available as indicated below to assist in caring for residents in the event of an emergency:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Per LPA’s file reviews, S1 and S2 who live in the facility, and are the only staff from 10pm to 6:00am,both S1 & S2 lack current first aid certification, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2023
Plan of Correction
1
2
3
4
Licensee to ensure that night staff from 10pm to 6am have required training in emergency procedures and has current first aid certification. Submit proof of having obtained first aid training as required: POC due 9/4/23.
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Per LPA's file reviews, there are no records on S3 as required, S3 states that they have been working approximately 1 1/2 years at the facility, the licensee did not comply with the section cited above in [1] out of [3] staff, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2023
Plan of Correction
1
2
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4
Licensee to ensure that staff three(3) has a complete file on-site available for review as required. Submit written self certification in writing that a staff file for S3 is complete and on-site available for review. POC due by 9/15/23.
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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023
LIC809 (FAS) - (06/04)
Page: 10 of 16


Document Has Been Signed on 08/29/2023 06:50 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: 08/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Per LPA's record reviews, R4 lacks all required forms but one; R4 only had a medical Assessment in their file, the licensee did not comply with the section cited above in [1] out of [5] resident records, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2023
Plan of Correction
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Licensee to ensure that there is a complete resident file with all required documents,all admission documents. and an Admission Agreement; Submit written self certification that the residents file is on-site and complete. POC due by 9/15/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023
LIC809 (FAS) - (06/04)
Page: 11 of 16


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: 08/29/2023
NARRATIVE
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The following deficiencies will be cited:

Based on Per LPA’s file review and interviews, the facility lacks required liability insurance; S2 stated they don't have the liability insurance and they can't buy it. This deficiency will be cited, 1569.605 Health & Safety- On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees, see LIC809D.

Based on LPA’s interviews and record reviews, There is no facility Administrator. LPA interviewed former Administrator LS, who stated they are not the Administrator since obtaining a full time job last year at Kaiser. This deficiency will be cited, H&S 1569.618(b) At least one administrator, facility manager, or designated substitute who is at least 21 years of age and has qualifications adequate to be responsible and accountable for the management and administration of the facility pursuant to Title 22 of the California Code of Regulations shall be on the premises 24 hours per day. The designated substitute may be a direct care staff member who shall not be required to meet the educational, certification, or training requirements of an administrator. The designated substitute shall meet qualifications that include, but are not limited to, all of the following, see LIC809D.



Based on LPA's interviews with staff, and record reviews, S1, S2, and S3 lacked current first aid certification as required. This deficiency will be cited, H&S 1569.618(c )(3) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR, see LIC809D.

Continued on LIC809C...
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
LIC809 (FAS) - (06/04)
Page: 12 of 16
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: 08/29/2023
NARRATIVE
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Based on LPA record reviews, and interviews, the facility has no qualified Administrator, and/or sufficient caregivers on staffing schedule. The one hired caregiver (S3) works from 7:45am to 12pm, leaves the facility, and returns at 3pm to work till 6pm. There are no other caregivers but S3, this deficiency will be cited, 87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services, see LIC809D.

Per LPA's interviews, and record reviews, Licensee has no Administrator, and has no qualified staff as a designee; S3 has no required training. S3 works 7:45am to 12pm and 3pm to 6pm. S1 & S2 lack First Aid & CPR certification, and no proof of required annual training This deficiency will be cited, 1569.618(a) Health & Safety -The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility, see LIC809D.

Per LPA's record reviews, and interviews, S3 has no required initial training and/or annual training as required by H&S 1569.625(b)(1); Per LPA record reviews, Staff S1 & S2 lack annual required training.
This deficiency will be cited, H&S 1569.625(b)(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training course work may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training, see LIC809D.
Continued on LIC809C...
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
LIC809 (FAS) - (06/04)
Page: 13 of 16
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: 08/29/2023
NARRATIVE
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Based on LPA's record reviews, S1, S2, and S3 all lack proof of current first aid certification. This deficiency will be cited, 87411(c)(1) Personnel Records General-(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross, see LIC809D.

Per LPA's interviews and record reviews, S3 lacks required initial medication training and annual required medication training; I4 who is not a staff or the Administrator, also assists residents with medications. I4 does not have required training to handle medications, per file reviews, S1 & S2 lack medication training per file reviews, and LPA interviews, the licensee did not comply with the section cited above in [3] out of [3] staff and a former staff I4 who lives on the property. This deficiency will be cited, H&S 1569.69(a)(2) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment, see LIC809D.

Based on LPA's record reviews, S3 lacked a health screening, LIC503 form, including a TB test and TB results. This deficiency will be cited, (f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties, see LIC809D.

Continued on LIC809C...
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
LIC809 (FAS) - (06/04)
Page: 14 of 16
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: 08/29/2023
NARRATIVE
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Based on LPA's record reviews, and interviews, the licensee has no qualified staff to be the designated substitute as required by H&S, This deficiency will be cited, H&S 1569.618(b)(3)At least one administrator, facility manager, or designated substitute who is at least 21 years of age and has qualifications adequate to be responsible and accountable for the management and administration of the facility pursuant to Title 22 of the California Code of Regulations shall be on the premises 24 hours per day. The designated substitute may be a direct care staff member who shall not be required to meet the educational, certification, or training requirements of an administrator. The designated substitute shall meet qualifications that include, but are not limited to, all of the following: (3) Training to effectively interact with emergency personnel in the event of an emergency call, including an ability to provide a resident’s medical records to emergency responders, see LIC809D.

Per LPA’s file reviews, S1 and S2 who live in the facility, and are the only staff from 10pm to 6:00am, lack current first aid certification. This deficiency will be cited, 87415(a) The following persons providing night supervision from 10:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures, shall be trained in first aid as required in Section 87465, Incidental Medical and Dental Care Services, and shall be available as indicated below to assist in caring for residents in the event of an emergency, see LIC809D.

Per LPA's file reviews, there are no records on S3 as required, S3 states that they have been working approximately 1 1/2 years at the facility. This deficiency will be cited, Personnel Records 87412(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information, see LIC809D.

Per LPA's record reviews, R4 lacks all required forms but one; R4 only had a medical Assessment in their file. This deficiency will be cited, 87506(b) Resident Records - Each resident's record shall contain at least the following information: All required documents upon admission, see LIC809D.

Per LPA's interviews, and observations, there was a low supply of sufficient perishable and non-perishable foods to meet the needs of the five clients meals and snacks, this deficiency will be cited,87555(b)(26) General Food Service Requirements. Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises, see LIC809D.

The LPA will be contacting the Licensee Flora Salonga to schedule a meeting in the Licensing office with Department Manager(s) and the LPA, in regards to the citations of today, and concern with the operation of this license/licensed facility.

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, and additional citations.

Appeal rights were provided.

Exit interview conducted with the Licensee Flora Salonga. Licensees spouse, S2, was also in attendance at the exit interview.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
LIC809 (FAS) - (06/04)
Page: 15 of 16
Document Has Been Signed on 08/29/2023 06:50 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: 08/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(26)
87555(b)(26) General Food Service Requirements. Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Per LPA's interviews, and observations, there was a low supply of sufficient perishable and non-perishable foods to meet the needs of the five clients meals and snacks, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2023
Plan of Correction
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Licensee to ensure there is a sufficient supply of perishable and non-perishable foods on-site at all times; Ensure to have a food supply that is able to provide residents with nourishing meals and snacks as required. Licensee to ensure food is bought for the facility in a sufficient supply for the faciility operation. Submit a copy of the food purchase receipt and a written self certification that the food is for the facility, POC due 8/30/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023
LIC809 (FAS) - (06/04)
Page: 16 of 16