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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003229
Report Date: 02/17/2022
Date Signed: 02/17/2022 10:25:00 AM


Document Has Been Signed on 02/17/2022 10:25 AM - 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, 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:
02/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Marjorie Reboja, AdministratorTIME COMPLETED:
10:35 AM
NARRATIVE
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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. During today's tour LPA observed the facility to have spiderwebs and unclean floors and bathrooms.

Deficiencies have been cited on 809-D.

Exit interview conducted and appeal rights given.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022
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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Document Has Been Signed on 02/17/2022 10:25 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 347003229

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)


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 keeping facility clean which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 03/04/2022
Plan of Correction
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Administrator agrees to deep clean the facility floors, bathrooms, walls, and kitchen. In addition administrator to send into CCL a plan of how staff will consistently keep facility clean. POC due on 3/4/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022
LIC809 (FAS) - (06/04)
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