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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003229
Report Date: 02/02/2023
Date Signed: 02/02/2023 01:24:27 PM


Document Has Been Signed on 02/02/2023 01:24 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:MARJORIE REBOJAFACILITY TYPE:
740
ADDRESS:7209 CROSS DRIVETELEPHONE:
(916) 723-4911
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:5CENSUS: 4DATE:
02/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Marjorie Reboja, Administrator TIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual.
LPA met with Marjorie Reboja, Administrator, and explained purpose of inspection. LPA observed (4) residents to be in their rooms at the start of the inspection. The facility is licensed for (5) non-ambulatory residents and has a hospice waiver for (1). Prior to initiating today's inspection, LPA completed required COVID-19 protocols. LPA was screened per Covid-19 precautionary measures upon entering the facility and wore the following PPE: surgical mask.

LPA and Administrator toured the interior and exterior of the facility including the common areas, (3) resident bedrooms, (2) full bathrooms, kitchen, and locked laundry area on the first floor. The second floor of the facility is used by the Administrator. LPA observed the facility to be clean, in good repair and odor-free. LPA observed the bathrooms to have the necessary grab bars, non-skid flooring, paper towels- Administrator to ensure a 20-second hand-washing poster is posted at each bathroom and kitchen sink. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food and additional food in an outside freezer. LPA observed medications and toxins to be secured nearby. LPA observed the inside temperature to be 77*F. Fire extinguisher was last serviced 7/29/2022. Discussed vaccination status of residents/staff, eligibility for boosters and updated visitation protocols. LPA observed multiple Covid posters posted as well as other required postings. The facility has an approved Mitigation Plan and will submit a completed Infection Control Plan (LIC9282). LPA observed some PPE on site- masks, sanitizer and gloves. LPA observed (1) unlocked gate from the inside back patio with covered patio seating.
LPA provided an updated copy of the license to reflect change in Licensee. Administrator to submit a request for an increase in the approved hospice waiver. LPA to provide various resources by email to facility following today's inspection. LPA discussed multiple topics with Administrator.

LPA requested an updated copy of LIC500, LIC308 and current liability insurance today by 2/9/23.
There are no deficiencies issued during today's inspection.
Exit interview with Administrator. Copy of report provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023
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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