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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701378
Report Date: 03/25/2026
Date Signed: 03/25/2026 07:53:36 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/02/2026 and conducted by Evaluator Cynthia Tamayo
COMPLAINT CONTROL NUMBER: 27-AS-20260202102942
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:
03/25/2026
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Harry AbellanaTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Staff does not ensure to meet residents' dietary needs.
INVESTIGATION FINDINGS:
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On 3/25/26, Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced to complete and close the investigation into an allegation noted above. LPA met with Administrator, Harry Abellana (S1) and stated the purpose of this visit.

Allegation: It was alleged that “Staff does not ensure to meet residents' dietary needs”, this investigation consisted of interviews with staff, residents, records review, and observations.

This investigation focused on Resident 5 (R5). Throughout the process, the LPA conducted facility observations during multiple visits, interviewed on duty staff and residents, collateral interviews, and reviewed all relevant documents related to R5. S1 stated that R5 had a diagnosis of diabetes and they tried to provide a variety of meals. There was no recent verification of training for staff regarding special dietary needs.
CONTINUED 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 27-AS-20260202102942
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/25/2026
NARRATIVE
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Collateral interviews corroborate staff does not ensure to meet residents' dietary needs. Collateral interview was conducted with Person 2 (P2) in which they did not express any concern around meals for R2;P2 stated that R2 does not have a special diet. LPA conducted a collateral interview with Witness 1 (W1), W1 stated, they and their family "had to purchase food out of pocket because the quality the facility provided was so low". One current resident (R4) stated that most meals does not usually include fresh fruit and vegetables and there is usually canned or frozen meals.

LPA observed French fries and fish stick was served for lunch. A custom lunch of veggies and fruit was provided to one resident(R4) per their request. On 2/4/26 and LPA observed meals consisted of frozen meals. Dinner on 3/25/26, was Chicken Alfredo and sweet peas (frozen). On 3/13/25, 2/4/26, and 3/25/26, LPA did not observed snacks to be provided in between meals.

LPA observed there is a sample menu available in the facility binder, however it is not followed on a daily basis; S1 stated the menu is used as a guide. S1 stated there are two main care staff whom are in charge of preparing meals but they are in charge of menu design. On 2/5/26, S1 stated they were tried out a meal service called "Hungry Root" which provide healthy meals. On 3/25/26, S1 stated he tried Hungry Rot for about three weeks in February but they did not continue the service due to the portions not being enough. S1 stated they are back to doing weekly groceries and will be improving meal options by seeking out additional education and resources.

Based on interviews and record review , the allegation "Staff does not ensure to meet residents' dietary needs" is substantiated.

As a result, the allegations above are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted and a copy of this LIC 9099, LIC 9099-D page and appeal rights was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/02/2026 and conducted by Evaluator Cynthia Tamayo
COMPLAINT CONTROL NUMBER: 27-AS-20260202102942

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:
03/25/2026
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Harry AbellanaTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Staff does not ensure resident's bathing needs are being met.
Staff isolates resident in bedroom for an extended period of time.
Staff does not ensure resident is properly dressed for the day.
Administrator does not ensure to be on premises for a sufficient number of hours.
INVESTIGATION FINDINGS:
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On 3/25/26, Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced to complete and close the investigation into an allegation noted above. LPA met with Administrator, Harry Abellana (S1) and stated the purpose of this visit.

1) It was alleged that “Staff does not ensure resident's bathing needs are being met” this investigation consisted of interviews with staff, residents, records review, and observations.

This investigation focused on Resident 5 (R5). As of February 2025, R5 no longer lives at the facility. LPA interviewed one resident, two collateral witnesses, and three staff. 3 out 3 (S1-S3) staff did not indicated staff do ensure resident's bathing needs are being met including those not receiving bathing services from home health providers. LPA was not able to interview four residents. One resident, Resident 4 (R4), did not express any concern around bathing needs. S1 stated there is a shower chair available for residents in care. On 2/4/26 and 3/25/26, LPA obseved all five resdeints looked clean and free of odors.
CONTINUED ON 9099A-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20260202102942
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/25/2026
NARRATIVE
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Based on interviews and record review of the LPA and review of records the allegation that "Staff does not ensure resident's bathing needs are being met" is unsubstantiated, as there is not a preponderance of the evidence to prove that the alleged violation occurred.

2) It was alleged that “Staff isolates resident in bedroom for an extended period of time.”, this investigation consisted of interviews with staff, residents, records review, and observations.

This investigation focused on Resident 5 (R5). As of February 2025, R5 no longer lives at the facility. LPA interviewed one residents, three collateral witnesses, and 3 staff. 3 out 3 three staff (S1-S3) declined the allegation that staff has isolated any resident in their bedroom for an extended period of time. LPA provided guidance care and supervision, personal rights, and activities. LPA was not able to interview four residents. Person 2 (P2 and Resident 4 (R4) did not express any concerns around the allegation that staff isolates resident in bedroom for an extended period of time. R4 stated they are usually in their room and is obtaining physical therapy services to try to be more active and less isolated. S1 stated residents are encouraged to come out of their room, but they sometimes do not want to and choose to stay in their rooms.

Based on interviews the allegation that “Staff isolates resident in bedroom for an extended period of time” is unsubstantiated as there is not a preponderance of the evidence to prove that the alleged violation occurred.


3) It was alleged “Staff does not ensure resident is properly dressed for the day”, this investigation consisted of interviews with staff, residents, records review, and observations.

This investigation focused on Resident 5 (R5). As of February 2025, R5 no longer lives at the facility. LPA interviewed one residents, two collateral witnesses, and three staff. 3 out 3 three staff (S1-S3) declined the allegation that staff does not ensure resident is properly dressed for the day. LPA provided guidance care and supervision, personal rights, and activities. LPA was not able to interview four residents out of five current residents. Person 2 (P2) and Resident 4 (R4) did not express any concerns around the allegation staff does not ensure resident is properly dressed for the day. S1 stated residents are assisted with dressing as needed.

CONTINUED ON 9099A-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20260202102942
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/25/2026
NARRATIVE
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Based on interviews and record review of the LPA and review of records the allegation that "Staff does not ensure resident is properly dressed for the day" is unsubstantiated, as there is not a preponderance of the evidence to prove that the alleged violation occurred.

4) It was alleged “Administrator does not ensure to be on premises for a sufficient number of hours”, this investigation consisted of interviews with staff, residents, records review, and observations.

LPA interviewed one resident, 2 collateral witnesses, and 3 staff. 3 out 3 three staff (S1-S3) stated that the Administrator is on premises often and available via phone at all times. LPA was not able to interview four residents out of five current residents. Person 2 (P2) did not express any concerns around the allegation that Administrator does not ensure to be on premises for a sufficient number of hours. LPA conducted a collateral interview with Witness 1 (W1), W1 stated, they only saw the administrator at the facility once ever 7-10 days during the four months they resided in the care home. Per LIC 500 indicated S1 is scheduled Monday- Friday between 8:00AM -12:00PM, S1 stated they are on-call/variable scheduled, "PRN" Monday- Sunday. S1 stated they do have another job as a Dialysis Technician. Resident 4 (R4) stated they see S1 at the facility about 3-4 times per week.

LPA provided guidance around Administrator Qualifications and expectations; as "The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section". Per Title 22 regulation 87405.

Based on interviews and record review of the LPA and review of records the allegation that “Administrator does not ensure to be on premises for a sufficient number of hours” is unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of four allegations listed above are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies cited per California Code Regulation, TITLE 22. Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was provided to Administrator (S1).
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20260202102942
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/30/2026
Section Cited
CCR
87555(a)
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87555 General Food Service Requirements (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents...shall be selected, stored, prepared and served in a safe and healthful manner...
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POC: BY POC due date, licensee/Administer shall submit a plan to ensure 87555 General Food Service Requirements. Licesee stated they will seek out additional resources such as dieticians and trainings. POC shall be faxed by POC due date to 916-263-4744
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This requirement is not met as evidenced by: Based on observation and interviews which corroborate the facility is not meeting dietary needs for residents, this poses a potential risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6