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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803900
Report Date: 05/18/2021
Date Signed: 05/18/2021 01:59:42 PM

Document Has Been Signed on 05/18/2021 01:59 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:SHILOH GREEN MANOR IIFACILITY NUMBER:
496803900
ADMINISTRATOR:ORTEGA, LIGAYAFACILITY TYPE:
740
ADDRESS:1182 VINTAGE GREENS DRIVETELEPHONE:
(707) 837-5761
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY: 6CENSUS: 5DATE:
05/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Licensee, Joy OrtegaTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced to conduct an Annual Required inspection and met with Licensee, Joy Ortega. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA observed that facility has hand sanitizer outside of the facility and a table just inside the entrance to the facility with hand sanitizer, a thermometer, disinfectant wipes and a sign in sheet. A staff took LPA's temperature and asked screening questions. LPA conducted a walk-through of the facility and observed Covid-19 posters throughout the facility that included hand-washing signs in each bathroom. Facility screens residents three times per day and staff daily for Covid-19 symptoms and documents in a log binder. Facility also logs when staff disinfect the facility which is twice per day. Licensee confirmed that 25% of staff are surveillance testing weekly. LPA observed five residents in care, four in their rooms and one in the living room. Per Licensee, two residents eat in their room and three eat in the dining room but are staggered. Facility staff have completed PPE training and have been N-95 Fit tested.

Facility has submitted a Covid Mitigation Plan. LPA observed more than 30 days of PPE including gloves, face shields, masks and gowns. All staff had masks on during this visit.

LPA confirmed that Licensee has reviewed PINs 21-17-ASC and 21-17.1-ASC.



No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2021
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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