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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803954
Report Date: 01/24/2023
Date Signed: 01/24/2023 03:36:46 PM

Document Has Been Signed on 01/24/2023 03:36 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: 6DATE:
01/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Barbara Santos-Lead CaregiverTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA), Dina Alviso, conducted a Required-1 Year inspection and met with Barbara Santos, caregiver. Caregiver contacted the Licensees/Administrators Joy and Manuel Ortega, who arrived a short time later. 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. Fire clearance is approved for six (6) non-ambulatory, which includes one bedridden clearance (RM #6.) Fire extinguishers, two (2), were serviced and tagged as required, expires December 14, 2023.

There were six(6) residents in care at the facility during this inspection. Four(4)) 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.

Continued on LIC809C....
Hope DeBenedetti
Dina Alviso
DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2023
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SHILOH GREEN MANOR OF SANTA ROSA
FACILITY NUMBER: 496803954
VISIT DATE: 01/24/2023
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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). Staff have PPE, including masks for use as needed. Residents have masks available to them for their use if needed and/or wanted.

LPA observed that staff Barbara who answered the front door, was seen without having a mask on, before opening the door to the LPA. This deficiency will be cited, Personal Rights 87468.1-see LIC809D.

Medication keys were left in the medication door leaving medications accessible to residents in care. A knife blade tool was left on a low stool accessible to residents in care. These deficiencies will be cited, Care of Persons with Dementia 87705(f)(1)(2)-see LIC809D.

California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited, see LIC809D. Failure to correct deficiencies as required may result in civil penalties being assessed.
Exit interview conducted with the Administrator Joy Ortega.
Appeal Rights Given.
SUPERVISOR'S NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/24/2023 03:36 PM - It Cannot Be Edited


Created By: Dina Alviso On 01/24/2023 at 02:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SHILOH GREEN MANOR OF SANTA ROSA
FACILITY NUMBER: 496803954

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/25/2023
Section Cited

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87705(f)(1)(2) Care of Persons with Dementia- The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).-Over-the-counter medication, nutritional
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supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement was not met as evidenced by LPA's observation-knife blade tool left on a foot stool in the livngroom-medication keys were hanging in the medication closets doorlock/doorknob.This is a risk to health & safety and/or personal rights to residents in care.
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inaccessible to residents in care. Hold an in-service traiining with all staff regaridng locking and securing medications and tool/ items that pose a risk to residents, submit proof of training by 2/1/23. Submit plan of correction by /25/23.
Type A
01/25/2023
Section Cited

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Personal Rights 87468.1(a)(2)- Residents in assited living.-ensuring personal rights are not violated at any time. This requirement is not met as evidenced by: LPA's observations during the inspection.
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Caregiver Barbara Santos was observed not wearing a surgical mask as required. Staff held back from opening the door to let the LPA in as they were trying to get a mask on.This is a risk to health & safety and/or personal rights to residents in care.
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Hold an in-service traiining with all staff regaridng required mask wearing by staff. Submit proof of training by 2/1/23. Submit plan of correction by /25/23.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Hope DeBenedetti
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2023


LIC809 (FAS) - (06/04)
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