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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801890
Report Date: 03/04/2021
Date Signed: 03/04/2021 04:48:49 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:PENNGROVE SHANGRI-LAFACILITY NUMBER:
496801890
ADMINISTRATOR:BACANI, MARIA CORAZONFACILITY TYPE:
740
ADDRESS:1762 WEISS LANETELEPHONE:
(707) 795-7921
CITY:PENNGROVESTATE: CAZIP CODE:
94951
CAPACITY:6CENSUS: 2DATE:
03/04/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Cora Bacani - AdministratorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Carla Fernandes-Goes, Technical Support Analyst (TSA) Richard Gasparine , and TSP LPM Kim met with Licensee Teddy Rico and Administrator Cora Bacani. This meeting was conducted virtually due to COVID-19.

This meeting is being conducted to discuss restarting TSP (Technical Support Program) to handle concerns identified by the Licensing Agency in regards to the operation of this facility including but not limited to:

* Medication Management
* Record Keeping
* Basic Services & Supplies
* Personnel/Training
* Using a second building on the property for staff.

As per discuss in this meeting, facility licensee Teddy Rico and administrator Cora Bacani agrees to continue with Technical Support Program which will be conducted virtually starting on 3/16 at PM time. The meeting will be conducted through Zoom. Licensee and Administrator will participate on this technical support.


There were no deficiencies cited at this time.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021
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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