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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003229
Report Date: 03/06/2025
Date Signed: 03/06/2025 05:49:03 PM

Document Has Been Signed on 03/06/2025 05:49 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SHADY OAKS CARE HOMEFACILITY NUMBER:
347003229
ADMINISTRATOR/
DIRECTOR:
MARJORIE REBOJAFACILITY TYPE:
740
ADDRESS:7209 CROSS DRIVETELEPHONE:
(916) 723-4911
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 5TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
03/06/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
05:15 PM
MET WITH:Marjorie Reboja, Administrator TIME VISIT/
INSPECTION COMPLETED:
05:45 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 inspection to follow up on (2) incident reports received. LPA met with Marjorie Reboja, Administrator, and stated the reason for today's inspection. A required annual inspection was also conducted today.

LPA and Administrator discussed the following incidences between residents (R1 and R2), as follows:

On February 6, 2025, (R1) hit (R2) in the face after (R2) allegedly annoyed (R1) in their shared room. Neither resident was injured and the Administrator spoke to each resident about the reason for the occurrence.

On February 13, 2025, (R1) hit (R2) again in the face after both residents were arguing with each other.

The same day, (R1) moved to a private room and (R2) moved to a shared room with another resident. There have been no subsequent incidences since. The Administrator talked to both resident's responsible persons, and they agreed with the room change. They had only been roommates for about (2) weeks when the first incident happened.

Administrator took (R1) to the emergency room following the second incident. (R1) was evaluated and returned the same day with no medication changes. (R1) has a diagnosis of Dementia. Administrator will update his care plan (due 3/19/25) and include these incidences.

Administrator will continue to monitor them and let the families and Department know if there are any future incidences.
There are no deficiencies cited in this report. Exit interview. Copy of report provided.
Maribeth SentyTELEPHONE: (916) 263-4813
Sabrina CalzadaTELEPHONE: (510) 829-2133
DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2025
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 1