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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801890
Report Date: 10/19/2022
Date Signed: 10/19/2022 02:18:16 PM


Document Has Been Signed on 10/19/2022 02:18 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:BACANI, MARIA CORAZONFACILITY TYPE:
740
ADDRESS:1762 WEISS LANETELEPHONE:
(707) 795-7921
CITY:PENNGROVESTATE: CAZIP CODE:
94951
CAPACITY:6CENSUS: 5DATE:
10/19/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Jesus Briones, staffTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct a Case Management Legal/Non-compliance inspection and met with staff Jesus Briones. Administrator Maria Bacani was unavailable during time of visit. The inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly.
LPA toured the facility, all exits were unobstructed. Facility has a COVID-19 screening station (visitor sign-in sheet, thermometer, hand sanitizer). LPA recommended facility add a COVID questionnaire (with screening questions) to their sign-in sheet. Staff and resident's temperatures are taken daily and documented. Facility food supply was inspected and found to be within regulation. There are a total of 5 smoke detectors and 1 carbon monoxide detector, which were tested and observed operational. Fire extinguisher was charged and serviced 01/07/2022. The facility has a supply of PPE including gloves, hand sanitizer, N-95 respirators, gowns, face shields, and surgical masks. During this visit, LPA verified staff COVID-19 vaccination records. A review of resident and staff records was conducted.
LPA discussed the following items with staff:
    · Facility to document resident Appraisal/Needs & Service Plans on required form LIC 625 (not LIC 603A) annually or when there is a change in condition for resident.
    · Ensure bathrooms have a garbage can with lid at all times
    · Implement a COVID questionnaire in visitor sign-in binder to ensure all visitors are being asked the screening questions
LPA requested the following items be submitted to the California Department of Social Services, Community Care Licensing by 11/07/2022:
    · Infection Control Plan copy
    · Monkey pox Addendum to Infection Control Plan copy
    · Documentation on completion of N-95 Respirator FIT testing for staff (Cal/OSHA requirement).
Exit interview conducted with staff Jesus Briones, whose signature on this document confirms receipt.
**No deficiencies cited during this inspection
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022
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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