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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803695
Report Date: 09/01/2023
Date Signed: 09/01/2023 01:51:23 PM


Document Has Been Signed on 09/01/2023 01:51 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
SANTA ROSA RO, 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: 6DATE:
09/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and met with Licensee John Ortega.

LPA initiated a tour of the facility around 12:45pm and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Facility has three residents on hospice, which is allowable per their approved hospice waiver. Resident rooms were furnished per regulation. Water temperature in bathroom used by residents measured at 117 degrees F which is within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cabinets containing cleaning supplies were locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked. Emergency food and water supplies are stored in the garage along with Personal Protective Equipment.

Fire extinguishers were last serviced January 2023. Smoke and Carbon Monoxide detectors located throughout the facility were tested and operational during inspection. Most recent fire/disaster drill was conducted 7/2023.

Three staff files and six resident files were reviewed. Staff have required First Aid and CPR certificates. Administrator Certificate for Administrator, Ligaya "Joy" Ortega 6015180740 expires 4/7/2024. Medications and medication records were reviewed. Training records were also reviewed.

Facility provided LPA a copy of their updated lease.

Continued on LIC809C
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SHILOH GREEN MANOR
FACILITY NUMBER: 496803695
VISIT DATE: 09/01/2023
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Continued from LIC809

Licensee/Administrator to submit updates of the following documents by 10/01/2023:


LIC 500 Personnel Summary
Copy of Liability Insurance
LIC 610 Emergency Disaster Plan (If changes)
Infection Control Plan (If changes)

No deficiencies cited during this inspection
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023
LIC809 (FAS) - (06/04)
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