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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801890
Report Date: 08/03/2023
Date Signed: 08/03/2023 03:26:01 PM


Document Has Been Signed on 08/03/2023 03:26 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: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:
08/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Teddy Rico, LicenseeTIME COMPLETED:
03:45 PM
NARRATIVE
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License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual required – 1 yr. visit of the facility. LPA was welcomed by staff Joyce Torres. LPA met with Teddy Rico, Licensee. There is a total of 6 residents and 3 with a diagnostic of dementia. There is one resident currently on Hospice.

LPA toured the facility on 8/3/2023 at 10:50 AM with licensee, Teddy Rico; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were equipped with auditory devices which were working properly at the time of the visit. Fire Extinguisher was found to be last charged on 1/23/2023 at the time of the visit. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Hot water temperature measured between 114.9 degrees F and 115.8 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 3 of 3 resident’s bathrooms while touring facility on 8/3/2023. The facility serves residents with dementia and has a plan of operation for special care and programming. There was a sufficient supply of both perishable and nonperishable food as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Sharps were stored in locked drawer in kitchen although some knives were also observed by LPA and licensee on 8/3/2023 at 11:01am in unlocked kitchen drawer (see LIC809-D). Toxins stored in a cabinet in the garage has broken lock (see LIC809-D) and exit door from kitchen to garage was turned off at the time of the visit on 8/3/2023 at 11:05 am (see LIC809-D). There was a supply of cleaners, hygiene products and paper products available for residents. The bathrooms designated for residents at the facility were supplied with individual paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. All bedrooms have lighting & appropriate furnishings. Resident’s beds were outfitted with mattress pads as required by Title 22 Regulations # 87307 on 8/3/2023 at 11:10 AM.

Continue on LIC 809-C

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023
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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Document Has Been Signed on 08/03/2023 03:26 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: PENNGROVE SHANGRI-LA
FACILITY NUMBER: 496801890

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 4 out of 4 areas (see pics) in the facility had disinfectants/cleaning solutions inaccessible to clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2023
Plan of Correction
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Licensee shall provide refresher training for all staff on the requirements of 87309 and will provide proof of completion to CCL as well as Licensee is designating additional locked cabinets in laundry area and fix lock on cabinet in garage for cleaning solutions to be safely stored. POC due date is 8/04/2023 to clear the deficiency.
Type A
Section Cited
CCR
87309(b)
Storage Space
(b) Medicines shall be stored as specified in Section 87465(c) and separately from other items specified in (a) above.

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 3 bags of medications for disposal were stored in unlocked kitchen cabinet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2023
Plan of Correction
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LIcensee to dispose of medication at appropriate location and send proof of receipt to CCL by POC due date of 8/4/2023
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: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/03/2023 03:26 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: PENNGROVE SHANGRI-LA
FACILITY NUMBER: 496801890

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA’s observation of many medication bottles in unlocked kitchen cabinet, medications were accessible to residents in care. This is an immediate Health and Safety risk to residents in care. LIcensee removed medications during visit.
POC Due Date: 08/04/2023
Plan of Correction
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Administrator agrees to submit self-certification that all medications are locked and inaccessible to residents in care. Administrator agrees to submit POC to CCL by 8/4/2023
Type A
Section Cited
CCR
87705(f)(1)
87705(f)(1)Care of Persons w/Dementia - The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).This requirement is not met as evidenced by

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, knives were found in unlocked kitchen drawer accessible to residents which poses an immediate health, Safety risk to residents in care. LPA toured the facility at 11:01 AM & observed unlocked sharps. (Photos taken)
POC Due Date: 08/04/2023
Plan of Correction
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Administrator to ensure that all sharp objects are stored in a locked storage inaccessible to residents at all times. Administrator to submit an LIC 9098 self certification that all items that can constitute danger to residents have been made inaccessible with a written statement signed by staff that staff understands this regulation to CCL by POC of 8/4/2023.
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: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PENNGROVE SHANGRI-LA
FACILITY NUMBER: 496801890
VISIT DATE: 08/03/2023
NARRATIVE
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A review of five resident & four staff records as well as two resident’s medications was conducted. LPA reviewed resident’s files at 11:45 AM on 8/3/2023 and learned that 3 of 5 residents have an updated re-appraisals/needs (R1 & R2 re-appraisals have not been updated see LIC 809-D) & care plans and physician’s assessments (LIC 602A).

Medications were centrally stored in a locked cabinet, pre-poured (see LIC9102 TV) in the facility kitchen area; although during tour on 8/3/2023 at 10:55 am with licensee, medications to be disposed were found in kitchen cabinet not containing a lock (see LIC 809-D). The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 8/3/2023 at 10:00 AM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate.

LPA reviewed a sample of staff records at 8:45 AM on 8/3/2023 and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. Direct care staff annual training requirements for 2022 are on file. LPA was presented with proof of CPR & 1st Aid although 1 of 4 staff did not have current 1st Aid (see LIC 809-D) certification for staff that files were reviewed. Jordan Rico Administrator Certificate # 6039905740 expires on 5/19/2024.

LPA reviewed Licensing Information System (LIS) with administrator who stated that is corrected and updated at this time; no need to change any of the information other than the mobile phone number. In addition, LPA advised facility to check with the County regarding what is the County Emergency Plan; ensure that disaster drills are conducted in different shifts, and review facility emergency plan to ensure accuracy according to the needs of facility residents. Disaster Drills have been conducted often with the last one being conducted on 5/19/2023.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided..



Continue on LIC 809-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 08/03/2023 03:26 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: PENNGROVE SHANGRI-LA
FACILITY NUMBER: 496801890

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
87463(c) Reappraisals- (c)The licensee shall arrange a meeting with the resident, the resident’s representative... when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first... This requirement has not been met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA/Licensee's file review showing that resident's care plans for 2 out of 2 residents (R1 & R2) were not been performed and signed by the resident of their representative within last 12 months. This is a potential risk to the health and safety of residents in care.
POC Due Date: 08/31/2023
Plan of Correction
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Administrator agreed to review all resident's care plans, update them accordingly and send self-certification that this process had been done to CCL by POC due date.
Type B
Section Cited
CCR
87411(c)(1)
87411(c)(1) PERSONNEL REQUIREMENTS GENERAL; Staff shall receive first aid training from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff files review & interview with Licensee, the facility did not ensure that all staff have current 1st aid. LPA learned that 1 of 4 staff (S1) does not have proof of current first aid certification which poses a potential health & safety risk to residents in care.
POC Due Date: 08/18/2023
Plan of Correction
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Licensee to ensure that all staff have current first aid certification at all times. Licensee to submit proof of First Aid Certification for staff S1 to CCL by POC date of 8/18/2023
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: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023
LIC809 (FAS) - (06/04)
Page: 5 of 7


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PENNGROVE SHANGRI-LA
FACILITY NUMBER: 496801890
VISIT DATE: 08/03/2023
NARRATIVE
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LPA Hansen is requesting Licensee to submit update documents to CCL by 9/3/2023:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of updated Lease Agreement
Copy of Administrator Certificate
Copy of Certificate of Liability Insurance
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
LIC809 (FAS) - (06/04)
Page: 7 of 7