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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003229
Report Date: 11/09/2022
Date Signed: 11/09/2022 01:33:22 PM


Document Has Been Signed on 11/09/2022 01:33 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: 3DATE:
11/09/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Marjorie Reboja, Administrator TIME COMPLETED:
01:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a follow up case management inspection. 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.

The purpose of today's inspection is to issue a deficiency related to the facility not timely reporting the death of Co-Licensee, Pedro Reboja, within (1) day of the date of passing, or 8/14/22. The Department was informed by email on 10/31/22 by the Administrator, Marjorie Reboja, of Co-LIcensee's passing. The Department requested a copy of the death certificate on 11/2/22 when LPA was able to respond to the email, and also provided information on what additional paperwork is needed to proceed in changing the entity from a partnership to a sole or corporation.

Regulation 87111 states the following: (b) In the event of a licensee's death, an adult who has control of the property, and had been designated by the licensee as the party responsible to continue operation of the facility upon a licensee’s death shall: (1) notify the Department by the next working day of the licensee’s death; (2) inform the Department within 5 working days if the designee decides not to apply for licensure.

LPA and Administrator discussed the options again during today's inspection and LPA provided with the contact number to the Department's Centralized Application Bureau (CAB). Administrator stated she would like to add Co-Administrator, Justine, to the license. Administrator, Marjorie, has been Administrator since 2006. LPA to change in the system.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency is issued on the 809-D page.

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: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022
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 11/09/2022 01:33 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: 11/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/23/2022
Section Cited

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87111 Continuation of License Under Emergency Conditions (b) In the event of a licensee's death, an adult who has control of the property, and had been designated by the licensee as the party responsible to continue operation of the facility upon a licensee’s death shall:

(1) notify the Department by the next working day of the licensee’s death;
This requirement is not met as evidenced by:
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Based on e-mail communication with Administrator, the death of Co-Licensee on 8/14/2022 was not reported to the Department until 10/31/2022, which posed a potential health and safety risk to residents in care.
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022
LIC809 (FAS) - (06/04)
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