496801890-9-12-2021-21-AS-CFGS-C6ST34-20210912142143

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496801890
Report Date: 09/09/2021
Date Signed: 09/12/2021 02:21:57 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-LA		FACILITY NUMBER:	496801890
ADMINISTRATOR:	BACANI, MARIA CORAZON		FACILITY TYPE:	740
ADDRESS:	1762 WEISS LANE		TELEPHONE:	(707) 795-7921
CITY:	PENNGROVE	STATE: CA	ZIP CODE:	94951
CAPACITY:	6	CENSUS: 5	DATE:	09/09/2021
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Maria Bacani - Administrator		TIME COMPLETED:	11:50 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPA) Fernandes-Goes conducted an unannounced Case Management Non-Compliance Infection Control inspection to this facility and was welcome by Jesus Briones. Administrator Cora Bacani was contacted by staff an arrived during the visit. Facility has 5 residents with and no one on hospice care at this time. Facility has activities for residents during the day. LPA arrived at the facility and had her temperature checked and logged into visitor’s binder. During facility tour on 9/9/2021 with Administrator Cora Bacani, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. However, LPA observed that garage has a room built a staff room in the garage which has not been fire cleared as per Title 22 Regulations and Health & Safety Code requirements. (see pictures, LIC 809-D, Civil Penalty) During TSP – Technical Support Program that the Department offered the facility to ensure compliance, it was discussed with facility licensee Teddy Rico and Administrator Cora Bacani the process to have a staff room build in the garage. LPA Fernandes-Goes at different occasions question administrator if facility was still planning to build a staff room in the garage. Administrator and licensee didn’t follow the process. At today’s visit LPA observed a room in the garage and inside the room it was observed bed with sheets, blanket, pillows, medications for staff S1, TV, dresser, money, as well as stored items. (see copy of sketch & pictures) Resident’s bedrooms, common areas, garage, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 12/2020 at the time of the visit. Smoke Detectors & Carbon monoxide detector were operational. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator was properly stored as per regulations on this day at the time of the visit. Facility has no residents with special dietary need at this time. Food is available for residents any time of the day. Facility takes residents on walks, and conduct activities during the day such as singing. Toxins are stored in a locked garage cabinet. There was a supply of cleaners, hygiene products and paper products available for residents. Continue LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

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: 09/09/2021

NARRATIVE

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All bathrooms designated for residents at the facility were supplied with towels and hand soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. Facility hot water temperature at residents' bathroom faucet measured 114.2 degrees F within Title 22 acceptable regulations of 105 to 120 degrees F.

Continue LIC 809-C

Infection Control:
Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility and entrance has table with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in small storage cabinet in living room. Facility has hired staff and admitted new residents since COVID-19.

Residents’ medications are stored and locked in kitchen cabinet. Facility has a 30-day supply of medication for residents. Residents aren’t wearing masks inside the facility, however; licensee/admin stated that they are able to wear masks when going on outings. All staff had masks on during this visit, however; staff S1 had mask on neck and stated that was eating at the time. Facility understands that unvaccinated staff must be tested once a week if PCR and vaccinated staff doesn’t need to be tested at this time if staff is able to show proof of vaccination which copy of vaccination card must be kept on facility file for staff at this time according with PIN 21-32-ASC & PIN 21-32.1-ASC: UPDATED FACILITY STAFF TESTING AND MASKING GUIDANCE FOR CORONAVIRUS DISEASE 2019 (COVID-19) In addition, facility to follow updated guidelines for visitors according with PIN 21-40-ASC: UPDATED STATEWIDE VISITATION WAIVER, AND TESTING AND VACCINATION VERIFICATION GUIDANCE FOR VISITORS RELATED TO CORONAVIRUS DISEASE 2019 (COVID-19)

In addition, facility allowing visitors in the facility. Residents have also available Zoom and telephone calls when contacting with family members and others. Staff had all PPE training required on file and have had N-95 fit testing last 12/2020.

Continue LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

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: 09/09/2021

NARRATIVE

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LPAs advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills have been conducted with the last one being conducted on 7/17/2021. Administrator understand that disaster drills must be conducted quarterly and in different shifts to ensure that all staff will participate as per Health & Safety Code #1569.695 Emergency Plans.

In addition, LPA gather more information regarding incident report that was submitted to the Department by the facility.

Civil Penalties are also being assessed in the amount of $500 due to zero tolerance citation issued.

*****Total Civil Penalties issued today in the amount of $500.00

Appeal of Rights Given.

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.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/09/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/10/2021 Section Cited	1 2 3 4 5 6 7	Fire Clearance:All facilities shall maintain a fire clearance approved by the city,county, or city & county fire department, or district providing fire protection services... This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	Based on observation & interview licensee didn't comply with this section above in 1 of 1 facility fire clearance on file which poses an immediate risk to health & safety of residents in care. Facility has a staff sleeping rest area room that was build in the garage. (see pic, CP)	8 9 10 11 12 13 14	in the report.Licensee also toensure that staff won't be sleeping in facility common areas and/or submit updated sketch for fire clearance & maintain no staff until clearance granted. Submit POC no later than 9/10/2021.
	1 2 3 4 5 6 7
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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: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

LIC809 (FAS) - (06/04)

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