Little Shangri-La Care Home

Allegation investigated: Staff does not ensure to meet residents' dietary needs.

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 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. 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 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).the state’s words, verbatim · CDSS document, Mar 25, 2026 · control 27-AS-20260202102942

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(a) · Plan of correction due date: Mar 30, 2026

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... 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.the state’s words, verbatim · CDSS document, Mar 25, 2026

Plan of correction: 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

Type of visit: Case Management - Deficiencies

On 3/25/26, Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced to conduct a case management deficiency visit. LPA met with Administrator, Harry Abellana (S1) and stated the purpose of this visit. On 3/25/26, it was learned Resident 4 (R4) had three Emergency Room (ER) visits due to pain episodes. The last ER visits for R1 was 3/20/26 and 3/22/26. S1 stated they did not know they had to report if a resident is sent out to the ER even if they were not admitted, hospitalized, or kept for evalution LPA provided guidance on reporting requirements to S1. LIC 9102 TV provided. Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Mar 25, 2026

Type of visit: Required - 1 Year

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 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.the state’s words, verbatim · CDSS document, Feb 4, 2026

Type of visit: Required - 1 Year

On 3/13/25 at 1:30 PM Licensing Program Analysts (LPAs) Cynthia Tamayo and Kevin Gould arrived at LITTLE SHANGRI-LA CARE HOME for the purpose of conducting a required 1 year annual inspection. LPAs met with Staff, Celia (Liza) Flor and together conducted a tour of the home. LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPAs observed a pool in the back yard that is fully enclosed by fencing that meets regulations and is inaccessible to residents without supervision. LPAs reviewed 3 Resident and 3 Staff files. Tuberculosis verification missing for one staff member. LPAs observed 2 of the 3 staff files reviewed did not meet the requirements for 20 hours of annual training including dementia training. LPA measured the water temperature, temperature measured at 118.5 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents. LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report, LIC 9020 client roster and current administrator certificate. Per California Code of Regulations, Tittle 22, the following deficiencies are cited during today’s inspection. An exit interview was conducted with facility staff and a copy of this report and appeal rights were provided to the facility.the state’s words, verbatim · CDSS document, Mar 13, 2025

Type of visit: Prelicensing

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.the state’s words, verbatim · CDSS document, Mar 5, 2024

Type of visit: Prelicensing

On 2/29/24, Licensing Program Analyst (LPA) Tung Truong arrived announced to conduct a Pre-Licensing inspection of the facility to ensure compliance with Title 22 regulations. Upon arrival, facility staff Jenny Roberts was present and contacted Applicant/Administrator Harry Abellana. Applicant was unable to come to the facility and advised staff Roberts to assist LPA with today’s inspection and sign the report. It was learned that this facility will be licensed to serve up to 6 non-ambulatory residents of which 1 may be bedridden in room #4 only. There were five (5) residents present during today's pre-licensing visit. LPA toured the facility with Jenny Roberts. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed the facility is clean and furnished. LPA observed rooms to have required furniture. The temperature inside the facility was observed to be at 74*F which is within the required range of 68-85*F. Hot water temperature was measured at 115.5*F and is within the required range of 105-120*F. LPA observed knives and toxins to be locked away and inaccessible to clients. Smoke and carbon detectors were in good repair. Fire extinguishers and first aid kit were up to date. LPA observed the centrally stored medication areas to be locked and made inaccessible to the residents at this time. LPA observed a swimming pool on the premises that is surrounded by a fence. At the time of this inspection the fence surrounding the swimming pool was observed to be locked. 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. The applicant/administrator was not present during today’s visit and has not completed Component III before; therefore, LPA Truong will return at a later date to complete the pre-licensing inspection. The applicant has not passed the pre-licensing component of the application process today. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 29, 2024