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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003229
Report Date: 02/10/2026
Date Signed: 02/10/2026 01:37:32 PM

Document Has Been Signed on 02/10/2026 01:37 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SHADY OAKS CARE HOMEFACILITY NUMBER:
347003229
ADMINISTRATOR/
DIRECTOR:		MARJORIE REBOJAFACILITY TYPE:
740
ADDRESS:7209 CROSS DRIVETELEPHONE:
(916) 723-4911
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 5CENSUS: 4DATE:
02/10/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Marjorie Reboja, Administrator TIME VISIT/
INSPECTION COMPLETED:
01:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual.
LPA met with Peter Reboja, who stated the administrator would arrive shortly. LPA observed (2) residents present in the common area and (2) residents resting in their rooms. The facility is licensed for (5) non-ambulatory residents and has a hospice waiver for (2). Currently, there is (1) resident on hospice. LPA observed a hospice staff and Physical Therapist present during today's inspection.

LPA and Administrator toured the interior/exterior of the facility including the common areas, (3) resident bedrooms, (2) full bathrooms, kitchen, and locked laundry area on the first floor. The second floor of the facility is used by the Administrator. LPA observed the bathrooms to have the necessary grab bars, skid-resistant flooring, hygiene supplies and trash can. LPA observed sufficient 2+day perishable, including
fresh produce, and 7+day non-perishable supply of food. Sharps and medications not requiring refrigerations are locked in the kitchen, and toxins are secured in the laundry area. Fire extinguisher was last serviced 9/22/2025, and the smoke monoxide alarms are working. There are required postings in the common area, including Resident Rights. The facility completed the last fire drill in January 2026. Inside temp measured 73*F . Hot water measured 127*F in a resident bathroom- a sign is posted. Facility to monitor the temperature monthly. There is (1) unlocked gate from the inside back patio.

LPA reviewed (2) resident files and (3) staff files. Medications were reviewed for (2) residents- orders match medications being administered. Staff have current First Aid/CPR certifications. (2) staff have current RCFE Administrator certifications. Administrator RCFE Administrator certification #7003027740 (exp 2/10/2028). All staff is cleared/associated. LPA to provide additional resources by email. Discussed various topics also.
Per California Code of Regulations Title 22, (1) deficiency is issued on the 809-D page.
Exit interview. Copy of report and appeal rights provided to the Administrator.
NAME OF LICENSING PROGRAM MANAGER: Maribeth Senty
NAME OF LICENSING PROGRAM ANALYST: Sabrina Calzada
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 02/10/2026 01:37 PM - It Cannot Be Edited


Created By: Sabrina Calzada On 02/10/2026 at 12:58 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SHADY OAKS CARE HOME
FACILITY NUMBER: 347003229

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in as multiple unlocked medications requiring refrigeration were observed in the main refrigerator, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/11/2026
Plan of Correction
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Licensee/Administrator immediately placed the unlocked medications in a drawer in the refrigerator until a locked box can be purchased, later today. Administrator to provide LPA with photos showing the medications requiring refrigeration have been secured by February 11, 2026.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Maribeth Senty
NAME OF LICENSING PROGRAM MANAGER:
Sabrina Calzada
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2026


LIC809 (FAS) - (06/04)
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