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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801890
Report Date: 06/14/2021
Date Signed: 06/15/2021 08:58:04 AM

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: 3DATE:
06/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Cora Bacani - AdministratorTIME COMPLETED:
11:45 AM
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Licensing Program Analysts (LPAs) Fernandes-Goes & Hansen conducted an unannounced Annual Required – 1 yr. Infection Control & Non-compliance inspection to this facility and met with Cora Bacani Administrator. There are 3 residents present at the facility. Facility has activities planned for residents during the day.

LPA arrived at the facility and had her temperature checked and logged into system. During facility tour on 6/14/2021 with administrator; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 12/2020 at the time of the visit. There was a sufficient supply of both perishable and nonperishable foods 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. Toxins are stored under the kitchen sink. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. All resident’s bedrooms have lighting & appropriate furnishings.

Infection Control:
Facility has submitted a mitigation program plan that has been reviewed during this visit and approved. There was a need for adding staff responsible as infection control lead. Posters have been placed throughout the facility, and facility has a station at main entrance with thermometer, sign in log, hand sanitizer and other items designated for visitors and staff. Staff before coming into work have temperature checked.

Continue LIC 809-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
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-LA
FACILITY NUMBER: 496801890
VISIT DATE: 06/14/2021
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Facility has PPE supply stored in living room draws and container. There has been no new staff hired and new resident's admissions lately which have been tested and cleared before coming into facility. Residents’ medications are stored and locked in the medication cabinet at med room. Facility has a 30-day supply of medication for clients. Residents are not wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. All staff had masks on during this visit. In addition, facility has a designated area for visitors which are being allowed in the facility. Residents have also available Facetime, Zoom, and telephone calls when contacting with family members and others. Staff have had all PPE training required on file and acquired N-95 fit testing.

LPAs advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills have been conducted quarterly with the last one on 1/20/2021.

There were no deficiencies cited at this time.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021
LIC809 (FAS) - (06/04)
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