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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801890
Report Date: 08/26/2024
Date Signed: 08/26/2024 04:01:37 PM


Document Has Been Signed on 08/26/2024 04:01 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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:
08/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Jesus Briones - StaffTIME COMPLETED:
04:15 PM
NARRATIVE
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08/26/2024, Licensing Program Analyst (LPA) Loera and (LPM) Bertozzi conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. LPA and LPM met with Jesus Briones(Staff) Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently six(6) residents in care. Facility approved/cleared for six(6) non-ambulatory, one(1) bedridden, and hospice waiver for two(2).

At approximately 12:45pm, LPA and LPM toured the building and grounds. The facility was found to be at a comfortable temperature. LPA and LPM observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled and dated. LPA and LPM noticed railing on back porch was wobbly causing a potential hazard to residents in care. Air conditioning vent located on the floor near dining table was rusted and dented condition potentially causing a hazard to residents in care. Residents bathroom cabinet door was found to be in poor condition with the door coming off the hinge causing a hazard to residents in care (Deficiency cited).

All rooms were equipped with lighting, night stand, and drawers. All rooms were in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to residents in care were measured within the range of 105 to 120 degrees F. Fire extinguishers were last inspected January, 2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Toxins, sharps and other items that could pose threat if available to residents were found to be secured. LPA and LPM conducted spot medication count and found two out of four resident medication to not be recorded as required on the Centrally Stored Medication Record.

continued on LIC809-C

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5071
LICENSING EVALUATOR NAME: Anthony LoeraTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2024
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 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PENNGROVE SHANGRI-LA
FACILITY NUMBER: 496801890
VISIT DATE: 08/26/2024
NARRATIVE
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At approximately 1:30 pm, LPA and LPM conducted a review of four resident records. Four out of four resident files need a reappraisal plan (Deficiency cited).


At approximately 2:00 pm, LPA and LPM conducted review of four staff records/training. Upon a review of staff records, LPA and LPM found all staff to have current 1st Aid & CPR certification on file. However four out of four staff did not have the required medication training (Deficiency cited).

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC309- Administrative Organization
Liability Insurance
Current Lease

Exit interview conducted with Administrator and a copy of this report was provided.

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5071
LICENSING EVALUATOR NAME: Anthony LoeraTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/26/2024 04:01 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: PENNGROVE SHANGRI-LA
FACILITY NUMBER: 496801890

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 out of 4 resident files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/09/2024
Plan of Correction
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Licensee to submit self certifcation that reappraisals for all residents have been completed by 09/09/2024.
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in three out of three railings to be loose and wobbly, bathroom cabinet door to be in poor condition falling off the hinge, and the air vent located on floor found to be rusted and bent which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/09/2024
Plan of Correction
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Licensee to provide a written plan indicating when noted items will be repaired and how residents in care will be ensured while items are being fixed by POC due date, 9/9/2024.
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: Kimberley MotaTELEPHONE: (707) 588-5071
LICENSING EVALUATOR NAME: Anthony LoeraTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 08/26/2024 04:01 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: PENNGROVE SHANGRI-LA
FACILITY NUMBER: 496801890

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69
§1569.69 Employees assisting residents with self-administration of medication; training requirements (b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 out of 4 staff files reviewed did not have required medication training. Which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2024
Plan of Correction
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Licensee to provide proof of staff medication training by 09/26/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Kimberley MotaTELEPHONE: (707) 588-5071
LICENSING EVALUATOR NAME: Anthony LoeraTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4