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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803954
Report Date: 02/29/2024
Date Signed: 02/29/2024 04:50:01 PM


Document Has Been Signed on 02/29/2024 04:50 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:
02/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Barbara Santos-Lead CaregiverTIME COMPLETED:
04:55 PM
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Licensing Program Analyst (LPA) Alviso, conducted a Required- 1 Year inspection, at about 2:05pm on 2/29/24, and met with Barbara Santos, caregiver. Caregiver contacted the Licensees/Administrators Joy and Manuel Ortega, who arrived a short time later. The facility has six (6) residents in care.

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 (3), were serviced and tagged as required, expires 12/6/24. Facility has a required emergency disaster plan. Facility has a required infection control plan.

LPA reviewed six (6) resident files; All resident files were complete.

LPA reviewed six (6) staff files. All staff have criminal record clearance as required. All staff had current First Aid and CPR as required. All staff had required annual training completed.

LPA toured the facility with the Administrator. The home was clean and orderly. Hot water was checked at 111. degrees Fahrenheit All exits were clear. All common areas, hallways, bathrooms, and resident rooms had sufficient lighting for resident use. Facility had a sufficient supply of perishable and nonperishable food. Facility had a sufficient supply of hygiene products, paper products, and cleaning supplies. Medications were locked and inaccessible to residents in care. Toxins were locked and inaccessible to residents in care. Bathrooms had grab bars and non-slip mat for resident use.

The facility has supplies to meet the 72 hour shelter in place requirement.

Continued on LIC809C...
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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: 02/29/2024
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LPA is requesting the following documents be updated and submitted by 3/27/24:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan- review and submit (provide all information in all boxes as required)
Infection Control Plan- review and submit (provide all information as required)
Copy of LIC400 Handling of Client Cash Resources (complete the form even if not handling cash)
Copy of required Surety Bond (if handling cash)
Copy of Current required Liability Insurance
Copy of current Administrator Certificate

There are no deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2