496803954-2-19-2021-21-AS-DALO-BYE4PV-20210219181722

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803954
Report Date: 02/19/2021
Date Signed: 02/19/2021 10:54:11 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 MANOR OF SANTA ROSA		FACILITY NUMBER:	496803954
ADMINISTRATOR:	ORTEGA, MANUEL C. JR.		FACILITY TYPE:	740
ADDRESS:	2028 DENNIS LANE		TELEPHONE:	(707) 205-6907
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	6	CENSUS: 4	DATE:	02/19/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Joy and Manuel Ortega-Licensee/Administrator		TIME COMPLETED:	04:40 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) Alviso, conducted a prelicensing tele-video inspection, on 2/19/21 at approximately 2:30PM, and spoke with applicants Manuel and Joy (Ligaya) Ortega. This is a change of ownership application, and the applicant Manuel Ortega will be the facility's Administrator. This tele-inspection is being conducted for a pre-licensing and a component III orientation. The inspection is being conducted by tele-inspection due to COVID-19 precautions. LPA conducted the inspection by video conference call; The reader is advised that the LPA did not physically make a site visit. Santa Rosa Inspector approved a fire clearance for 6 nonambulatory residents, which includes 1 bedridden approval- effective 12/23/20. Facility has applied for a hospice waiver for four(4); Hospice waiver will be approved and effective once application is licensed. Facility submitted a dementia plan to be approved to care for dementia residents; Dementia plan is part of the facility's plan of operation, and will be effective upon licensure. LPA observed comfortable furnishings throughout the facility. The facility has a walkway and a ramp that leads to the front door. The facility has a large backyard with a deck and ramp, and patio furnishings are available for resident use. The backyard gate which is used as a fire exit off the outside ramp, was working properly and opened freely. There is a large sunroom off the living room area that leads out to the backyard, the sunroom is used for residents as wanted. There was sufficient lighting throughout the facility in resident rooms, common areas, bathrooms, and hallways. The grounds were free of any apparent hazards, and exits were clear. No bodies of water. No firearms. LPA observed a medication closet that has a door handle electric lock, all medications are inaccessible to residents in care. Kitchen had sufficient food supply for residents in care, and all kitchen equipment is in working condition. Continued on LIC809C...

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 MANOR OF SANTA ROSA	FACILITY NUMBER: 496803954
	VISIT DATE: 02/19/2021

NARRATIVE

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There was a sufficient supply of paper products, hygiene products, cleaners, and other items for resident use. All bathrooms had grab bars, and non-slip flooring/mats for resident use. All exit doors had auditory alarms working properly. Smoke alarms, carbon monoxide detectors were working properly during the inspection. Fire extinguishers were tagged and inspected as required. Facility had emergency supplies to meet requirement for the 72 hour shelter in place. Postings noted to be current and in compliance with regulations. Hot water was checked, 113.2F, and is within regulation of no lower than 105F and no higher than 120F. All toxins, cleaners, and items that may pose a risk to residents in care, were locked up and inaccessible to residents. Applicants have an emergency disaster plan, and our currently working on a mitigation plan that will be ready once they are licensed, per Manuel and Joy Ortega. Facility has a supply of Personal Protective Equipment (PPE) for use as needed. Applicants will have all their pandemic policies in place once they are licensed. Surveillance testing will be done for all staff every seven days, and mass testing when needed. Current facility licensee has their pandemic policies in place and has been completing surveillance testing. All postings required were posted up, and visible as required. LPA discussed ensuring that once applicants are licensed that they will post up their documents such as Administrator certificates, their license, their facility's documents that identify the facility name, Shiloh Green Manor of Santa Rosa.

LPA conducted a component III orientation with Applicants Manuel and Joy (Ligaya) Ortega, today 2/19/21.

Pre-Licensing is complete and this facility has no apparent health hazards and/or concerns observed during this tele-video inspection.

**Applicants are advised any structural changes to facility may require further inspection before final approval.

Copy of report to be faxed to Applicant for signature. LPA will forward a copy to the analyst in the application unit of Sacramento; The application analyst will notify the applicants of the status of their application. Manuel and Joy Ortega stated their understanding.

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2021

LIC809 (FAS) - (06/04)

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