342701378-2-5-2026-27-AS-CTAO-DQZMRF-20260205085016

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701378
Report Date: 02/04/2026
Date Signed: 02/05/2026 08:50:55 AM

Document Has Been Signed on 02/05/2026 08:50 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 HOME		FACILITY NUMBER:	342701378
ADMINISTRATOR/ DIRECTOR:	ABELLANA, HARRY		FACILITY TYPE:	740
ADDRESS:	10017 GEODE CT		TELEPHONE:	(518) 545-1491
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95829
CAPACITY: 6		CENSUS: 4	DATE:	02/04/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:59 AM
MET WITH:	Celia (lisa) Flor		TIME VISIT/ INSPECTION COMPLETED:	04:00 PM

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	On 2/4/2026, Licensing Program Analyst (LPA) Cynthia Tamayo arrived at LITTLE SHANGRI-LA CARE HOME for the purpose of conducting a required 1 year annual inspection. LPA met with Staff, Celia (Lisa) Flor (S2). An entrance interview was conducted. Upon arrival, the Administrator was not present at the facility, S2 called them to inform them of the purpose of today's visit. S2 arrived around 12:00 PM. LITTLE SHANGRI-LA CARE HOME is a Residential Care Home for the Elderly (RCFE), and is licensed to serve age range 60 and over. Approved for five (6) non-ambulatory residents, one (1) of which may be bedridden. Bedridden cleared in room #4. Waiver/granted for hospice care for four (4) residents. There are currently four residents in care of which three are in hospice and non are bed ridden per LIC 602s. LPA toured the facility with S1 and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 73 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 141 degrees Fahrenheit, which is not within the required range of 105 and 120 degrees. S1 stated they would have the water heater adjusted by 2/6/26. LPA Tamayo observed first aid supplies, a fully- charged and up-to-date fire extinguisher, and carbon monoxide/smoke detectors. LPA Tamayo observed a minimum 2- day supply of perishable food and a minimum 7-day supply of nonperishable food. Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 HOME	FACILITY NUMBER: 342701378
	VISIT DATE: 02/04/2026

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
26
27
28
29
30
31
32

LPA observed a locked cabinet for the storage of medication. LPA Tamayo observed locked cabinets for the storage of cleaning solutions and knives.

The exterior of the building was inspected by the LPA. LPAs observed a pool in the back yard that is fully enclosed by fencing that meets regulations and is inaccessible to residents without supervision, the yard was completely fenced in. There was also a sitting area for residents in the backyard.
Administrator certificate # 7031618740 and it expires 9/27/27.

LPA compared the LIC 500 with the roster of staff obtained from Guardian to ensure that all staff had the appropriate background clearances to be working with the residents in care. All were in compliance at the time of this inspection.

LPA requested the following documents:
LIC 500: Personnel Report , received
LIC 308: Designation of Administrative Responsibility, received
LIC 402: Surety Bond, if applicable
LIC 610E: Emergency Disaster Plan, received
LIC 309: (for any LLC or Corp) if applicable
Copy of Liability Insurance

According to the California Code of Regulations, Title 22, one deficiencies was observed or cited during today's visit. A copy of this report, 809-D, and appeal rights was provided and an exit interview conducted.

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 02/05/2026 08:50 AM - It Cannot Be Edited

Created By: Cynthia Tamayo On 02/04/2026 at 03:17 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LITTLE SHANGRI-LA CARE HOME	FACILITY NUMBER: 342701378
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as the water from the faucet is 141 degrees during this time, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/06/2026
	Plan of Correction
1 2 3 4	The facility's administrator agrees the water temperature measured 141 degrees Fahrenheit, which is not within the required range of 105 and 120 degrees. LPA observed S1 contact the property owner to adjust the new water heater during this visit and will ensure the water heater temperature is adjusted to be within regulation limits by 2/6/26. Administrator also stated they will start to keep a water temperature log.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:

	Cynthia Tamayo
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026

LIC809 (FAS) - (06/04)

Page: 4 of 4