<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490107833
Report Date: 10/12/2023
Date Signed: 10/12/2023 12:00:24 PM


Document Has Been Signed on 10/12/2023 12:00 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: 4DATE:
10/12/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Justina Martinez-CaregiverTIME COMPLETED:
12:00 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 a case management inspection, on 10/12/23 at approximately 9:40am, and was let into the facility by caregiver Justina Martinez. Licensee Flora Salongawas observed to be in bed in their room.
The caregiver stated there were four residents in care; One resident had been moved out due to needing higher level of care. Laila came into the facility to speak with the LPA. Laila is a relative of the Licensee, and is the former Administrator. Laila left to work in a different industry approximately a year and seven months ago (1.7 years). Ernesto Salonga arrived approximately 30 minutes after the LPA's arrival.

Per LPAs observations, interview with licensee, and other related parties, the Licensee Flora Shangrila has not ensured the facility has a qualified certified Administrator on-site as required by regulation; Per interviews the facility has not had an Administrator since former Administrator Laila Salonga left to another job 1.7 years ago. This deficiency will be cited, Administrator -Qualifications and Duties 87405 (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation, see LIC809D.

Licensing office will hold an office informal meeting with the Licensee; The LPA will send out the meeting notification letter once date is scheduled with the Licensee. The meeting will be conducted this month, October 2023.

Deficiencies are cited from the California Code of Regulations, Title 22, and/or California Health and Safety Code. Failure to correct the deficiencies may result in additional deficiencies and/or civil penalties being assessed.
Appeal rights were provided to Licensee Flora Salonga
Exit interview conducted with Flora Salonga.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 10/12/2023 12:00 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: 10/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/13/2023
Section Cited
CCR
87405(a)

1
2
3
4
5
6
7
Administrator - Qualifications and Duties 87405 (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.
1
2
3
4
5
6
7
Licensee to ensure that the facility has a hired Administrator on-site as required by regulations. The facility must have a qualified certified Administrator on-site to ensure the facility is operating within regulations.
8
9
10
11
12
13
14
This requirement was not met as evidenced by LPAs observations, and interview with licensee, and other related parties. he Licensee Flora Shangrila has not ensured the facility has a qualified certified Administrator on-site as required by regulation; there has not been an Administrator since former Administrator Laila Salonga left 1.7 years ago. This is a risk of health and safety and/or personal rights of all residents in care.
8
9
10
11
12
13
14
Submit all documents required to associate the hired Administrator, including copy of their certificate, and updated LIC500 personnel report by by 10/21/23. Plan of correction due 10/13/23.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 10/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2