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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803954
Report Date: 03/25/2022
Date Signed: 03/25/2022 05:06:25 PM


Document Has Been Signed on 03/25/2022 05:06 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 MANOR OF SANTA ROSAFACILITY NUMBER:
496803954
ADMINISTRATOR:ORTEGA, MANUEL C. JR.FACILITY TYPE:
740
ADDRESS:2028 DENNIS LANETELEPHONE:
(707) 205-6907
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:6CENSUS: 5DATE:
03/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:-Licensee/AdministratorTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA), Dina Alviso, arrived unannounced to conduct a Required-1 Year inspection and met with Licensee/Administrator, Joy and Manuel Ortega. The inspection is focused on the Infection Control procedures and practices of this facility.

Facility has an approved dementia plan of operation. There is an approved hospice waiver for four (4) residents. Mitigation plan was received and reviewed by the Department. Fire clearance is approved for six (6) non-ambulatory, which includes one bedridden clearance (RM #6.) Fire extinguishers were serviced and tagged as required, dated December 31, 2021.
There were five 5 residents in care at the facility during this inspection. Three(3) residents are on hospice care. All visitors, essential visitors, and staff are screened upon entry; Temperatures are taken, and screening questions are to be answered before being allowed to remain in the facility, all information is logged. Residents are screened twice daily, and observed for any changes, all information is logged. Facility was found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. Toxins are stored in locked cabinets. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Medications were stored locked making them inaccessible to residents and staff that do not handle medications. All exit alarms were on exit doors and working properly. All bathrooms had grab bars, and non-slip mat/flooring for bathing as needed. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment(PPE). Residents have masks available to them for their use if needed and/or wanted. Administrator stated that staff wear masks in the facility, and also when providing care services to the residents in and out of the facility. Administrator had a mask on during the LPA's inspection.
No deficiencies found in the areas inspected.
No citations issued.
Exit interview conducted with the Administrator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022
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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