Shangrila Healthcare

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced annual inspection visit. LPA was allowed entry by Maria Teresa Cerino. LPA spoke to Rocio Collado via telephone and discussed the purpose of today’s visit. This facility consists of (6) bedrooms, (1) staff/employee room, (3) full bathrooms, (1) ½ bathroom, utility room (laundry), living room, dining room, kitchen. This facility is currently approved for (12) AMBULATORY residents only. Per Ms. Collado, this facility will only be able to accommodate up to (9) residents and not (12) residents. This facility has not admitted any residents since becoming licensed. The following was discussed during the telephone call with Ms. Collado: Change in capacity- Ms. Collado was instructed to submit a new LIC 200/Application, facility sketch and a check to CDSS for the request of change in capacity. The new LIC 200 and facility sketch is to identify/reflect the total number of beds (including non-ambulatory). Request for non-ambulatory- Per Ms. Collado, there is an inspection pending with the Fire Department to move forward with this request. Ms. Collado will provide updates to LPA. Additionally, LPA briefly discussed dementia plan as potential residents with this diagnoses are considered to be non-ambulatory. This facility does not have a dementia plan in place. Refer to LIC 809C for the continuation of this report. Overdue licensing fees- LPA provided Ms. Collado the information (including PIN) to pay fees on-line today as they are due today. A copy of the facility transaction with PIN information was left at this facility and also sent via text to Ms. Collado. Liability Insurance: LPA requested a copy of the current insurance coverage. Guardian Portal- LPA discussed with Ms. Collado the requirement of having all staff finger print cleared and associated to this facility prior to accepting the first resident. Self-Assessment Guide (Residential Care Facility for the Elderly)- LPA discussed this tool and provided a copy. LPA also sent a picture of this document to Ms. Collado via text. LPA utilized the Compliance and Regulatory Enforcement (CARE) tool: Infection Control: Facility has an Infection Control Policy in place. Operational Requirements: This facility has not admitted any residents since becoming licensed. Physical Plant & Environment Safety: LPA toured facility grounds. Fire smoke alarms and carbon monoxide detector observed. The fire extinguishers observed and appeared to be full. Bedrooms have the required furniture. Bathrooms have non-skid surfaces and grab bars. Hot water temperature (156.4* in bathroom near bedroom #5 and 152.2 the other bathrooms (Advisor Note- Technical Violation issued as there are no residents residing at this facility. Staffing: This facility has not admitted any residents since becoming licensed. Personnel Records-Training: This facility has not admitted any residents since becoming licensed. Resident Rights-Information: This facility has not admitted any residents since becoming licensed. Planned Activities: This facility has not admitted any residents since becoming licensed. Food Service: This facility has not admitted any residents since becoming licensed. Resident Records-Incident Reports:This facility has not admitted any residents since becoming licensed. Disaster Preparedness: Facility has a disaster preparedness plan in place. Health Related Services/Incidental Medical Services: This facility has not admitted any residents since becoming licensed. Exit interview conducted, copy of appeal rights and this report was provided to Maria Teresa Cerino.the state’s words, verbatim · CDSS document, Sep 4, 2025

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Elizabeth Irra conducted a scheduled pre-licensing visit. LPA met with Rocio Collado (Applicant/Administrator), Anna Aldiano (Assistant Administrator) and Lucio Collado. This facility consists of (6) bedrooms, (1) staff/employee room, (3) full bathrooms, (1) ½ bathroom, utility room (laundry), living room, dining room, kitchen. This facility is approved for (12) AMBULATORY residents only. During this visit, LPA conducted a facility tour and conducted Component III. The following was observed/inspected: Smoke detectors operate properly. Carbon monoxide detector was tested and operable. Fire extinguishers located in the kitchen and near the dining room. Cleaning solutions (under kitchen sink) and sharps are locked in the kitchen. Building and grounds are free from hazards. Beds have the required linen/supplies. Bedrooms are large enough to allow for easy passage between and comfortable for usage of beds and other required items of furniture. There are enough bath towels, hand towels and wash cloths for all residents. There are sufficient amount of linens available to permit weekly changing to ensure use of clean linens at all times by residents. Facility has a washer and dryer that are fully operational located inside the utility room. Pantry's cupboards, freezers, stoves, microwaves, refrigerator and counters are clean. Two-day supply of perishables available, seven day supply of non-perishable available. Pesticides and other toxic substances are stored and locked away from food supply. Staff and Resident files (including resident medications) will be locked inside the staff/employee room. Refer to LIC 809C for the continuation of this report. Physical plant is in good repair. Building and grounds are free from hazards. Window screens are in good repair and windows/curtains/blinds are in good repair and operate properly. Refrigerator, stove, telephone, sinks, tubs, toilets and showers operate properly. Hot water temperature measured within regulation (115.5* to 117.5*) Pending: Surveillance Cameras: Applicant to follow up with Centralized Applicant Bureau (CAB) for guidance. Hospice Waiver: Applicant to follow up with Centralized Applicant Bureau (CAB) for status. Liability Insurance (H&S Code 1569.605): Applicant has not yet purchased as license has not been issued. Facility Sketch LIC 999: to be updated accordingly (staff/employee room to be reflected). Planned Activities/87219(d): Activity schedule missing. Telephone line/87311: Per Applicant, still awaiting for provider to connect this service. First Aid Manual/87465(a)(9)(A): Manual has a copyright year of 2018. Applicant to obtain most current copy. First Aid Kit/Thermometer/87465(a)(9)(F): Kit is missing the thermometer. Grab bars/87303(e)(4): All full bathrooms are missing grab bar near the toilets. Exit interview conducted, copy of report provided to Rocio Collado/Applicant.the state’s words, verbatim · CDSS document, Jun 13, 2024

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 12 Census (if any clients in care): 0 COMP II Participants: Rocio Collado Interview Method: Telephone interview On April 09, 2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restricted/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Apr 9, 2024