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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701378
Report Date: 03/05/2024
Date Signed: 03/05/2024 11:36:35 AM

Document Has Been Signed on 03/05/2024 11:36 AM - 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: 4DATE:
03/05/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Harry AbellanaTIME COMPLETED:
12:00 PM
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On 3/5/24, Licensing Program Analyst (LPA) Tung Truong arrived announced to complete the Pre-Licensing inspection. LPA met with Applicant, Harry Abellana who assisted LPA in today’s visit.

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. Component III was conducted with the applicant. LPA will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed.

Per the California Code of Regulations Title 22, no deficiencies were observed or cited.
Exit interview held, copy of report given.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2024
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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