<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003229
Report Date: 10/25/2022
Date Signed: 10/25/2022 12:54:08 PM


Document Has Been Signed on 10/25/2022 12:54 PM - 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: 1DATE:
10/25/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Marjorie Reboja, Administrator TIME COMPLETED:
01:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management health and safety inspection. LPA knocked on the door and waited a few minutes and then called the facility phone number. LPA spoke with Marjorie Reboja, Administrator, who greeted LPA at the front door. LPA explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 Department protocols. LPA was not screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. LPA confirmed there are no positive cases or staff/residents with symptoms upon entering the community.

LPA and Administrator toured the facility to ensure the safety and well being of residents in care. Administrator stated there is currently (1) resident at the facility as (1) resident went to the hospital yesterday, 10/24/22, for medical treatment needed. Admin to send in LIC624, incident report within a week. LPA observed the floors to be swept and the bathrooms to appear clean with paper towels and soap. Admin to post a 20-second hand-washing poster. LPA observed 2+ day perishable food and 7+day non-perishable food on hand. LPA spoke with resident (R1) who was in her room watching television. R1 indicated she receives three meals and snacks daily. LPA observed the fire extinguisher to have been last serviced 8/29/22 and the smoke/monoxide alarms to be in working order. Administrator changed a battery in the unit near the kitchen as it sounded "battery low". LPA confirmed on CCLD website that Administrator's certificate was renewed and is valid through 2/9/24, although the renewal certificate has not been received. Administrator confirmed that licensee mailing address needs to be updated to facility address. While inspecting the kitchen, LPA observed an unlocked sharp, toxin, several unlocked medications, and the file cabinet where medications are kept to not have a functioning lock. LPA also observed heavy build up of dust on the outside bottom piece of the refrigerator. LPA provided (3) bottles of individual hand sanitizers from the Department.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) citations is issued on the 809 D page. Advisory notes (2) are also being issued.
Exit interview. Copy of report and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 10/25/2022 12:54 PM - 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: 10/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2022
Section Cited

1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on observation on 10/25/22, at approximately 11:30 am, LPA observed (1) bubble pack of unlocked medications on top of the medication cabinet for resident (R3), expired medication for R1, and medications for R1 and R2 to not be secured due to the lock not functioning correctly on the medication cabinet, which poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2