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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803695
Report Date: 07/14/2022
Date Signed: 07/14/2022 01:01:43 PM


Document Has Been Signed on 07/14/2022 01:01 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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: 5DATE:
07/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Assistant Administrator Manuel "John" Ortega and Licensee/Administrator, Joy OrtegaTIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced to conduct an Annual Required inspection and met with Assistant Administrator, Manuel "John" Ortega. Licensee/Administrator, Joy Ortega arrived later. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA observed posters outside notifying visitors that mask must be worn in the facility. Once inside, LPA was screened by Assistant Administrator who checked LPA temperature and asked LPA to sign in. LPA confirmed that facility is conducting vaccination verification per Provider Information Notice (PIN) 21-40-ASC. LPA initiated a walk-through of the facility around 11:45 am and observed the following: Facility has COVID-19 posters throughout that included hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Observed staff had masks on during this visit. Commonly touched surfaces are disinfected twice per day and after use. Facility continues to screen residents daily and staff when they come on shift.

Facility has a designated visitation area outside and is allowing for visitation in resident rooms per CCL guidance. Staff continue to be trained on infection control and Personal Protective Equipment and have been N95 fit tested. Per Licensee, they will ensure that staff are N95 tested annually. LPA and Licensee discussed visitation and activities.

Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced January 2022. Smoke and carbon monoxide detectors throughout facility were tested and operational.

Continued on LIC809C

SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2022
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


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SHILOH GREEN MANOR
FACILITY NUMBER: 496803695
VISIT DATE: 07/14/2022
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Continued from LIC809C

Licensee and LPA discussed their Emergency Disaster Plan. Facility has submitted their Infection Control Plan.

Licensee/Administrator to submit updates of the following documents by 08/14/2022:

LIC 308 Designated Administrator
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (if any changes)
LIC 9020 Register of Facility Client’s/Resident’s
Copy of current Administrator's Certificate
Copy of current Lease/Rental Agreement
Copy of Liability Insurance

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: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2