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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801890
Report Date: 09/30/2021
Date Signed: 10/01/2021 10:04:43 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: 5DATE:
09/30/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Mary Quiambao - staffTIME COMPLETED:
12:34 PM
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Licensing Program Analysts (LPA) Fernandes-Goes conducted an unannounced Case Management Health Checks inspection to this facility and was welcome by Mary Quiambao - staff. Administrator Cora Bacani was contacted by phone and spoke with LPA during visit. Facility has 5 residents with no one on hospice care at this time. Facility has activities for residents during the day.

Facility has built a four wall room in the garage (picture on file) that was being used as a staff room. However, facility didn't acquire a permit and has no fire clearance for the garage room. Penngrove Fire Marshall contacted Department stating that room can only be used as a break/storage room and is waiting for fire alarm system before clearing room in garage for such. Administrator Cora Bacani understands that garage room can not be used as staff room at this time and will have mattress against the wall in this room removed. Penngrove Fire Marshall will be returning to the facility as per administrator Cora Bacani on 10/7/2021.

In addition, LPA reviewed files for residents due to a concern from Penngrove Fire Marshall regarding bedridden resident in a room designated for non-ambulatory. Per record review of 5 residents LIC 602 ambulatory status, there are 3 ambulatory & 2 non-ambulatory residents. (see LIC 811)


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: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
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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