Penngrove Shangri-La

Type of visit: Required - 1 Year

On 07/21/2026 at approximately 11:30AM, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to conduct 1-Year Required visit of this licensed Residential Care Facility for The Elderly (RCFE). LPA was greeted by Licensee, Teddy Rico. Facility has an approved fire clearance for capacity of six (6) non-ambulatory, of which one (1) may be bedridden. The facility currently approved hospice waiver for capacity of two (2) individuals. Upon arrival, LPA was informed that there were five (5) residents in care and two (2) staff members on-site. Facility is a 1 story building with five (5) Resident bedrooms, 2 bathrooms, and common spaces. LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 12:00 PM, LPA and Licensee toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Staff were in the process of preparing lunch and cleaning up kitchen at the time of this inspection. Toxins are stored inaccessible to residents. Water temperature measured 108.2 degrees F which is within regulation between 105- and 120-degrees F at faucets accessible to residents. Fire Extinguishers found to be last charged in December 2025 at the time of visit. Carbon Monoxide and smoke detectors were present and in order. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure in a cabinet in the living room. Continued on LIC809-C... Continued from LIC809… LPA reviewed four (4) resident records and found all residents have care plans, signed admission agreements, and physician's report on file. However, the facility failed to obtain the current resident medical assessment and care plans for all dementia residents in file (See LIC809-D page). The LPA is requesting that updated medical assessments and care plan for all residents be submitted to Community Care Licensing (CCL) by August 10, 2026. Medication records are thorough and contains doctor’s order LPA reviewed three (3) staff records. Facility failed to ensure that two (2) of three (3) staff members completed the required 20 hours of annual training. (Technical Violation Given). Licensee agrees to complete all the staff trainings. Evidence of current first aid and CPR training were current. LPA was presented with proof of current CPR & 1st Aid certification. Administrator Certificate for Florifess Hunt #7017206740 expires on 11/08/2027. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility failed to conduct and documented a disaster drill quarterly. Last drill was conducted on 07/08/2026 (Technical Violation Given). Updated copies of the following documents were requested for facility file and are to be submitted to CCL by due date of 08/0312026: -LIC 308 Designation of Facility Responsibilities -LIC 500 Personnel Summary -LIC 610 Emergency Disaster Plan (Last page) -LIC 9020 Register of Facility Client’s/Resident’s -Copy/Proof of Updated Certificate of Liability Insurance Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with caregiver and a copy of this report was given.the state’s words, verbatim · CDSS document, Jul 14, 2026

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On 04/21/2026, at approximately 10:00 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a case management- Other inspection and met with Ted Rico, Licensee. LPA is conducting a case management visit to inspect bedroom #5 located at the front of the facility which has been converted from a staff room to a resident room. Licensee sealed off the doorway from the kitchen to the bedroom and has installed a new door from the facility's main living room to bedroom #5. LPA observed all of the required furnishings, windows, window coverings, and a smoke and carbon monoxide detector which was tested and operational during inspection of the room. The local fire department has been out to clear the bedroom for resident occupancy, and today, LPA has cleared the use of this bedroom for resident occupancy. The conversion of this bedroom has not changed the facility's total approved occupancy as bedroom #2 was changed from a double occupancy bedroom to a single occupancy bedroom. No deficiencies were cited during todays visit. Exit interview was conducted with Ted Rico, Licensee, whose signature on form confirms receipt of document.the state’s words, verbatim · CDSS document, Apr 21, 2026

Type of visit: Required - 1 Year

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 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.the state’s words, verbatim · CDSS document, Aug 7, 2025

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

08/26/2024, Licensing Program Analyst (LPA) Loera and (LPM) Bertozzi conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. LPA and LPM met with Jesus Briones(Staff) Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently six(6) residents in care. Facility approved/cleared for six(6) non-ambulatory, one(1) bedridden, and hospice waiver for two(2). At approximately 12:45pm, LPA and LPM toured the building and grounds. The facility was found to be at a comfortable temperature. LPA and LPM 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. LPA and LPM noticed railing on back porch was wobbly causing a potential hazard to residents in care. Air conditioning vent located on the floor near dining table was rusted and dented condition potentially causing a hazard to residents in care. Residents bathroom cabinet door was found to be in poor condition with the door coming off the hinge causing a hazard to residents in care (Deficiency cited). 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 were measured within the range of 105 to 120 degrees F. Fire extinguishers were last inspected January, 2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Toxins, sharps and other items that could pose threat if available to residents were found to be secured. LPA and LPM conducted spot medication count and found two out of four resident medication to not be recorded as required on the Centrally Stored Medication Record. continued on LIC809-C At approximately 1:30 pm, LPA and LPM conducted a review of four resident records. Four out of four resident files need a reappraisal plan (Deficiency cited). At approximately 2:00 pm, LPA and LPM conducted review of four staff records/training. Upon a review of staff records, LPA and LPM found all staff to have current 1st Aid & CPR certification on file. However four out of four staff did not have the required medication training (Deficiency cited). 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 LIC309- Administrative Organization Liability Insurance Current Lease Exit interview conducted with Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 26, 2024

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Resident sustained unexplained injury while in care

Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 1:35PM to deliver findings regarding the above allegation. LPA was greeted by staff. Licensee, Teddy Rico arrived shortly after. LPA and Licensee and discussed the purpose of the visit. Complaint alleges that a resident sustained an unexplained injury in care. Throughout the course of the investigation, LPA reviewed documents, made observations, and conducted interviews. Per Resident 1s (R1s) physicians report, R1 has a history harming themselves from their fingernails. Interviews conducted with R1s family revealed that R1 has a history of biting their nails, biting their fingers, and scratching themselves. Family confirmed that R1 bruises easily. Family confirmed that R1 exhibited these same behaviors at previous care homes. Based on interviews conducted, documents reviewed and observations made, and while the allegation may be valid, there is not a preponderance of evidence to prove the alleged violations did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 26, 2024 · control 21-AS-20240126115507