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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490107833
Report Date: 02/27/2024
Date Signed: 02/27/2024 12:49:05 PM


Document Has Been Signed on 02/27/2024 12:49 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: 0DATE:
02/27/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Laila Salonga-Former StaffTIME COMPLETED:
12:55 PM
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Licensing Program Analyst (LPA) Alviso arrived to conduct a case management visit, on 2/27/24 at approximately 12:15pm, and met with Laila Salonga, former Administrator.

LPA toured the facility and observed no clients in care. Licensee Flora Salonga met with the Department, on 10/24/2023, and notified the Department that they wanted to surrender the license, as they no longer want to operate the care facility.

Laila Salonga provided the Department State of CA license to the LPA during the inspection.

The license is no longer valid. If wanting to operate a care home at this address in the future, an application would need to be filed with the Department, and applicant would go through the application process.

The facility license is closed today, effective 2/27/2024.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2024
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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