496803695-8-21-2024-21-AS-ALOA-D8CRFW-20240821125947

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803695
Report Date: 08/21/2024
Date Signed: 08/21/2024 01:11:11 PM

Document Has Been Signed on 08/21/2024 01:11 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 MANOR		FACILITY NUMBER:	496803695
ADMINISTRATOR:	ORTEGA, LIGAYA S		FACILITY TYPE:	740
ADDRESS:	7760 FOPPIANO WAY		TELEPHONE:	(707) 837-5133
CITY:	WINDSOR	STATE: CA	ZIP CODE:	95492
CAPACITY:	6	CENSUS: 5	DATE:	08/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Administrator - John Ortega		TIME COMPLETED:	01:25 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 Analysts (LPAs), Loera and Alviso, arrived unannounced to conduct a Required-1 Year Inspection, on 8/21/24 at approximately 9:10am. LPAs met with Administrator John Ortega. Facility has a required infection control plan. Facility has a required emergency disaster plan. Facility has an approved dementia plan. The facility has a hospice waiver for three (3) residents. Facility has a fire clearance approved for six (6) non-ambulatory, of which one (1) may be bedridden, in rooms #1,#2, and #5. LPAs toured the facility and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Facility outdoor area has several patio furnishings including umbrellas with shade, pathways were cleared. Exit door from kitchen leads onto a ramp to the backyard fire exit gate. The facilities front door leads to a ramp that is a fire exit. Facility has one (1) resident on hospice, which is allowable per their approved hospice waiver. Resident rooms and hallways had sufficient lighting. Facility has smoke alarms and two (2) carbon monoxide detectors. All exits had working auditory alarms. Water temperature in bathroom used by residents measured at 111.5 degrees, which is within regulation (105 to 120 degrees). Resident bathrooms had grab bars and non-slip mats/floors in showers. Extra hygiene products and linens were available. Cabinets containing cleaning supplies were locked and inaccessible to residents in care. Laundry room containing cleaning supplies, soaps, and disinfection's were locked and inaccessible to residents in care. Medications were centrally stored and locked and inaccessible to residents in care. 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. Emergency food and water supplies are stored in the garage along with Personal Protective Equipment. Last fire/evacuation drill was conducted 07/04/24, per file review. LPAs reviewed five (5) resident files. Continued on LIC809C...

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5071
LICENSING EVALUATOR NAME: Anthony Loera	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

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: 08/21/2024

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LPAs reviewed four (4) staff files. All staff had required training, criminal record clearance, First-Aid, and CPR certification.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC309- Administrative Organization
Liability Insurance
Current Lease

No Deficiencies Cited

Exit interview conducted with Administrator and a copy of this report was provided.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5071
LICENSING EVALUATOR NAME: Anthony Loera	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

LIC809 (FAS) - (06/04)

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