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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003229
Report Date: 12/08/2021
Date Signed: 12/08/2021 01:32:02 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:SHADY OAKS CARE HOMEFACILITY NUMBER:
347003229
ADMINISTRATOR:REBOJA, PEDROFACILITY TYPE:
740
ADDRESS:7209 CROSS DRIVETELEPHONE:
(916) 723-4911
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:5CENSUS: 4DATE:
12/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Marjorie Reboja, AdministratorTIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct an annual inspection. LPA met with Administrator Marjorie Reboja during today's inspection. LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Masks.

LPA toured facility with staff to ensure health and safety of residents in care. LPA toured 4 resident rooms, upstairs staff area, bathrooms, kitchen, common living spaces, and backyard. LPA toured upstairs staffing area, and only staff and family live upstairs. In the areas toured no immediate health, safety, or personal rights violations were observed. Administrator stated there are no positive COVID cases at the facility, but have an isolation room and sufficient amount of PPE. LPA and staff completed the infection control domain and LPA printed out resources and information related to COVID.

Administrator to send into CCL a current administrator certificate, current LIC 500, and liability insurance.

No deficiencies are being cited as a result of todays inspection. Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021
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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