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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801890
Report Date: 08/07/2025
Date Signed: 08/07/2025 03:46:16 PM

Document Has Been Signed on 08/07/2025 03:46 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:PENNGROVE SHANGRI-LAFACILITY NUMBER:
496801890
ADMINISTRATOR/
DIRECTOR:		JORDAN RICOFACILITY TYPE:
740
ADDRESS:1762 WEISS LANETELEPHONE:
(707) 795-7921
CITY:PENNGROVESTATE: CAZIP CODE:
94951
CAPACITY: 6CENSUS: DATE:
08/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Teddy Rico, LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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08/6/2025, Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. LPA was greeted by Chris Gabay(Staff) who contacted Licensee Teddy Rico that arrived shortly after. Facility is single story, 4 resident bedroom, Residential care facility for the elderly. There are currently five(5) residents in care. Facility approved/cleared for six(6) non-ambulatory, one(1) bedridden, and hospice waiver for two(2).

At approximately 8:15am, LPA and staff toured the building and grounds and was joined by Licensee. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled and dated.
All rooms were equipped with lighting, night stand, and drawers. All rooms were in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to residents in care measured 131.1 degrees F & 132.4 degrees F not within range of 105 to 120 degrees F (see LIC809D). Licensee turned water heater down. Fire extinguishers were last inspected 1/3/2025. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Toxins-laundry detergent observed in laundry closet unlocked (see pics) & cleaning supplies observed in unlocked cabinet in garage (see pics), sharps observed in kitchen drawer with broken lock (see pics) and other items that could pose threat if available to residents were found to be unsecured(see LIC809D). LPA conducted spot medication count and found five out of five resident medication to not be recorded as required on the Centrally Stored Medication Record (see LIC809D). Medications for residents were pre-poured for the full day (see LIC809D). Resident prescription bottles were written on by staff (see pics & LIC9102-TA).
Continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2025
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 6
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)
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Document Has Been Signed on 08/07/2025 03:46 PM - It Cannot Be Edited


Created By: Shannan Hansen On 08/07/2025 at 12:04 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: 08/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (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
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Based on observation, the licensee did not comply with the section cited above in two out of two resident bathroom faucets measured 131.1 degrees F & 132.4 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2025
Plan of Correction
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Licensee to submit a 10 day water temperature log. Log to be started on 08/08/2025 and end on 08/18/2025. Log to include date, location of sink, water temperature, and time of temperature check and submitted to CCL by POC due date of 08/18/2025.
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in finding toxins-laundry detergent observed in laundry closet unlocked (see pics) & cleaning supplies observed in unlocked cabinet in garage (see pics), sharps observed in kitchen drawer with broken lock which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2025
Plan of Correction
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Licensee shall provide refresher training for all staff on the requirements of 87309 and will provide proof of completion to CCL as well as Licensee to submit self certification (by 8/8/25) they understand the regulation and fix lock on kitchen drawer containing sharps (fix drawers) . Submit proof of new locks and trainings of staff, POC due date is 8/15/2023 to clear the deficiency.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Shannan Hansen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/07/2025 03:46 PM - It Cannot Be Edited


Created By: Shannan Hansen On 08/07/2025 at 12:04 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: 08/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's & LIcensees observation, interview , and record review, the licensee did not comply with the section cited above in spot medication count found five out of five resident medication to not be recorded as required on the Centrally Stored Medication Record which poses/posed a potential health, safety or personal rights risk to persons in care. The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year.
POC Due Date: 08/15/2025
Plan of Correction
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Facility to submit LIC9098 self-certifying all medications for all residents is listed on their respective Centrally Stored Medication logs .
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA & Licensee observation, the licensee did not comply with the section cited above in 5 out of 5 residents medications were pre-poured for the entire day, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2025
Plan of Correction
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Facility to conduct in-service training for all staff to review regulation 87465(h)(5). Training to include the following information: Date, Training Topic, Name/Job Role, and Signatures by POC due date of 8/15/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Shannan Hansen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2025


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: 08/07/2025
NARRATIVE
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Continued from LIC809

At approximately 10:00 am, LPA conducted a review of five resident records. Five out of five resident files had appropriate documentation.


At approximately 11:15 am, LPA conducted review of five staff records/training. Upon a review of staff records, LPA found all staff are background cleared and associated to facility as well, have current 1st Aid & CPR certification on file. All five out of five staff have the required trainings on file.

Disaster drills have been conducted quarterly with the last being on 7/12/2025. Facility has generator in garage in case of emergency. Administrator certificate for Jordan Rico #7011840740 expires on 5/19/2026.

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..

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility (if changes)
LIC309- Administrative Organization
LIC 610 Emergency Disaster Plan (if changes)
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance

Exit interview conducted with Licensee and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
LIC809 (FAS) - (06/04)
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