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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490107833
Report Date: 10/25/2023
Date Signed: 10/25/2023 11:32:59 AM


Document Has Been Signed on 10/25/2023 11:32 AM - 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:
10/25/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Flora Salonga-LicenseeTIME COMPLETED:
11:32 AM
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A informal meeting was conducted today in the Santa Rosa Regional Office. Present in the meeting were Lice?nsing Program Manager Bethany Moellers, Licensing Program Analyst Dina Alviso, and representative ????of the facility, Licensee Flora Salonga. Licensee also had her family members in attendance, Laila Salonga, and Ernesto Salonga.

The purpose of the informal conference was explained to the Licensee. Items addressed in today's meeting include but are not limited to compliance issues outlined below:
.
· Licensee to ensure there is sufficient staffing to meet residents care 24/7

Items needed:.

· LIC500 personnel report, showing all staff, titles, days, and time working at the facility. Submit by 10/31/23.

Licensee stated their understanding that not submitting plan of corrections (POCs) by due dates, may warrant additional citations and civil penalties to be assessed.

Licensee stated they have decided to close the facility, and submit a closure plan by November 1, 2023. Licensee will submit a copy of the 60 day written notice provided to all residents and responsible parties. Licensee will keep the Department notified as residents transfer out to new care facilities.

No deficiencies cited during today’s informal non-compliance office visit.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2023
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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