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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003229
Report Date: 03/16/2022
Date Signed: 03/16/2022 10:43:40 AM


Document Has Been Signed on 03/16/2022 10:43 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:
03/16/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Marjorie Reboja, AdministratorTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a POC 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.

On 2/17/22, LPA cited facility for being unclean. During today's inspection LPA toured the facility with administrator and observed facility to be in clean and sanitary. In addition, Administrator sent LPA a schedule of when and how facility will be cleaned in the future. Deficiency has been cleared and letter of clearance printed for administrator.

In addition, Administrator has submitted an application for liability insurance and will send LPA a copy of proof of insurance once received.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022
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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