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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801890
Report Date: 02/03/2022
Date Signed: 02/08/2022 11:24:24 AM

Document Has Been Signed on 02/08/2022 11:24 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
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:
02/03/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Cora Bacani - AdministratorTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analysts (LPA) Fernandes-Goes conducted an unannounced Case Management Non-Compliance Infection Control inspection to this facility and was welcome by Administrator Cora Bacani. Facility has 4 residents with no one on hospice care at this time. Facility has activities for residents during the day.

LPA arrived at the facility and had her temperature checked and logged into visitor’s binder. During facility tour on 2/3/2022 with Administrator Cora Bacani, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, garage, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 1/2022 at the time of the visit. LPA conducted a sample test of Smoke Detectors & Carbon monoxide detector and they were operational. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator was properly stored as per regulations on this day at the time of the visit. Facility has no residents with special dietary need at this time. Food is available for residents any time of the day. Facility takes residents on walks, and conduct activities during the day such as singing. Toxins are stored in a locked garage cabinet. There was a supply of cleaners, hygiene products and paper products available for residents.

All bathrooms designated for residents at the facility were supplied with towels and hand soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. Facility hot water temperature at residents' bathroom faucet measured between 115.8 degrees F and 117.6 degrees F in 2 out of 2 residents’ faucets within Title 22 acceptable regulations of 105 to 120 degrees F. In addition, Department learned that staff S1 has been working in the facility since 11/2021, however; she is not fingerprint cleared according with Guardian. LPA w/ administrator contacted office staff at Regional Office and confirm that staff is not fingerprint cleared and there was no information regarding why it is taking this long (see confidential name list, LIC 809-D, civil penalty) Continue LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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-LA
FACILITY NUMBER: 496801890
VISIT DATE: 02/03/2022
NARRATIVE
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Infection Control:
Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility and entrance has table with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in small storage cabinet in living room. Facility has hired staff and admitted new residents since COVID-19.

Residents’ medications are stored and locked in kitchen cabinet. Facility has a 30-day supply of medication for residents. Residents aren’t wearing masks inside the facility, however; licensee/admin stated that they are able to wear masks when going on outings. All staff had masks on during this visit. Facility understands that unvaccinated staff must be tested once a week if PCR and vaccinated staff doesn’t need to be tested at this time if staff is able to show proof of vaccination which copy of vaccination card must be kept on facility file. In addition, facility is allowing visitors in the facility. Residents have also available Zoom and telephone calls when contacting with family members and others. Staff had all PPE training required on file and is working towards N-95 fit testing.

LPAs advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills have been conducted with the last one being conducted on 10/23/2021. Administrator understand that disaster drills must be conducted quarterly and in different shifts to ensure that all staff will participate as per Health & Safety Code #1569.695 Emergency Plans.

Immediate Civil Penalties are being assessed in the amount of $500 due to staff not being associated to the facility.

*****Total Civil Penalties issued today in the amount of $500.00

Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/08/2022 11:24 AM - It Cannot Be Edited


Created By: Carla Fernandes-Goes On 02/03/2022 at 12:51 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PENNGROVE SHANGRI-LA
FACILITY NUMBER: 496801890

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/04/2022
Section Cited
CCR
87355(e)(1)

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87355(e)(1) Criminal Record:All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility:Obtain a California clearance or a criminal record exemption ...
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Facility to ensure that all staff is fingerprint cleared and associated to the facility before working in a licensed facility. Facility to submit a self certification to the Department as proof that staff S1 who is not
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This requirement is not met as evidenced by:Based on obs. & file review,the licensee didnot comply w/section cited above in 1 out of 2 staff fingerprint clearance which poses an immediate health, safety or personal rights risk to persons in care.LPA interviewed Adm & learned that staff S1started working on 11/20/21,however has no fingerprint clearance>(CP)
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fingerprint cleared will not be working, voluntering, and/or residing at the facility until fingerprint cleared by POC date of 2/4/2022.

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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.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2022


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