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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496801890
Report Date: 04/26/2024
Date Signed: 04/26/2024 03:19:06 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/26/2024 and conducted by Evaluator Helena Rummonds
COMPLAINT CONTROL NUMBER: 21-AS-20240126115507
FACILITY NAME:PENNGROVE SHANGRI-LAFACILITY NUMBER:
496801890
ADMINISTRATOR:JORDAN RICOFACILITY TYPE:
740
ADDRESS:1762 WEISS LANETELEPHONE:
(707) 795-7921
CITY:PENNGROVESTATE: CAZIP CODE:
94951
CAPACITY:6CENSUS: 6DATE:
04/26/2024
UNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Licensee, Teddy RicoTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained unexplained injury while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 1:35PM to deliver findings regarding the above allegation. LPA was greeted by staff. Licensee, Teddy Rico arrived shortly after. LPA and Licensee and discussed the purpose of the visit.

Complaint alleges that a resident sustained an unexplained injury in care. Throughout the course of the investigation, LPA reviewed documents, made observations, and conducted interviews. Per Resident 1s (R1s) physicians report, R1 has a history harming themselves from their fingernails. Interviews conducted with R1s family revealed that R1 has a history of biting their nails, biting their fingers, and scratching themselves. Family confirmed that R1 bruises easily. Family confirmed that R1 exhibited these same behaviors at previous care homes.

Based on interviews conducted, documents reviewed and observations made, and while the allegation may be valid, there is not a preponderance of evidence to prove the alleged violations did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Helena RummondsTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 1