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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803695
Report Date: 08/13/2021
Date Signed: 08/13/2021 04:14:41 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:SHILOH GREEN MANORFACILITY NUMBER:
496803695
ADMINISTRATOR:ORTEGA, LIGAYA SFACILITY TYPE:
740
ADDRESS:7760 FOPPIANO WAYTELEPHONE:
(707) 837-5133
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY:6CENSUS: 6DATE:
08/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Licensee, Joy OrtegaTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced to conduct an Annual Required inspection and was greeted by staff. Licensee, Joy Ortega arrived later. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA observed that facility has hand sanitizer outside of the facility and a table just inside the entrance to the facility with hand sanitizer, a thermometer, disinfectant wipes and a sign in sheet. A staff took LPA's temperature and asked screening questions. LPA conducted a walk-through of the facility and observed that all exits were free from obstructions and Covid-19 posters were posted throughout the facility that included hand-washing signs in each bathroom. Facility screens residents twice a day and staff daily for Covid-19 symptoms and documents in a log. Facility also logs when staff disinfect the facility which is twice per day and as needed. Per Licensee, 100% of staff and residents are vaccinated so they have discontinued surveillance testing per CCL guidance. LPA observed six residents in care, three in their rooms and three in the living room. Per Licensee, two residents eat in their room and three eat in the dining room but are staggered. Facility staff have completed PPE training and have been N-95 Fit tested. Facility allows for visitation and has two designated visitation areas; one in the garage and one outside.

Facility has submitted a Covid Mitigation Plan that was reviewed by CCL on July 12, 2021. LPA observed more than 30 days of PPE including gloves, face shields, masks and gowns. All staff had masks on during this visit.

Smoke alarms were tested and operational. LPA and Licensee discussed facility's Emergency Disaster Plan.

No deficiencies cited during this inspection.

SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021
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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