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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701378
Report Date: 02/29/2024
Date Signed: 02/29/2024 03:58:36 PM

Document Has Been Signed on 02/29/2024 03:58 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:LITTLE SHANGRI-LA CARE HOMEFACILITY NUMBER:
342701378
ADMINISTRATOR:ABELLANA, HARRYFACILITY TYPE:
740
ADDRESS:10017 GEODE CTTELEPHONE:
(518) 545-1491
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY: 6CENSUS: 5DATE:
02/29/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Jenny RobertsTIME COMPLETED:
04:20 PM
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On 2/29/24, Licensing Program Analyst (LPA) Tung Truong arrived announced to conduct a Pre-Licensing inspection of the facility to ensure compliance with Title 22 regulations. Upon arrival, facility staff Jenny Roberts was present and contacted Applicant/Administrator Harry Abellana. Applicant was unable to come to the facility and advised staff Roberts to assist LPA with today’s inspection and sign the report.

It was learned that this facility will be licensed to serve up to 6 non-ambulatory residents of which 1 may be bedridden in room #4 only. There were five (5) residents present during today's pre-licensing visit. LPA toured the facility with Jenny Roberts.

LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed the facility is clean and furnished. LPA observed rooms to have required furniture. The temperature inside the facility was observed to be at 74*F which is within the required range of 68-85*F. Hot water temperature was measured at 115.5*F and is within the required range of 105-120*F. LPA observed knives and toxins to be locked away and inaccessible to clients. Smoke and carbon detectors were in good repair. Fire extinguishers and first aid kit were up to date. LPA observed the centrally stored medication areas to be locked and made inaccessible to the residents at this time. LPA observed a swimming pool on the premises that is surrounded by a fence. At the time of this inspection the fence surrounding the swimming pool was observed to be locked.

Based on a review of this facility during this Pre-licensing visit, it was determined that this facility was found to be in compliance at this time. The applicant/administrator was not present during today’s visit and has not completed Component III before; therefore, LPA Truong will return at a later date to complete the pre-licensing inspection. The applicant has not passed the pre-licensing component of the application process today.

An exit interview was conducted, and a copy of this report was provided.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/29/2024
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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