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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803900
Report Date: 07/23/2024
Date Signed: 07/23/2024 01:36:11 PM

Document Has Been Signed on 07/23/2024 01:36 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SHILOH GREEN MANOR IIFACILITY NUMBER:
496803900
ADMINISTRATOR/
DIRECTOR:
ORTEGA, LIGAYAFACILITY TYPE:
740
ADDRESS:1182 VINTAGE GREENS DRIVETELEPHONE:
(707) 837-5761
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY: 6CENSUS: 6DATE:
07/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Joy & John Ortega-Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Alviso arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Licensees Joy and John Ortega. There are currently six (6) residents in care. There was a caregiver working with the Administrators during the inspection.
Facility has a required infection control plan. Facility has a required emergency disaster plan. Facility has an approved dementia plan. The facility has a hospice waiver for four (4) residents. Facility has a fire clearance approved for six (6) non-ambulatory, of which one(1) may be bedridden.
LPA reviewed six (6) resident files. Medication records and storage of medications were checked. All medications were locked and inaccessible to residents in care. LPA reviewed three (3) staff files. All staff have required criminal record clearance. Staff have required training. Staff have first aid certification and cpr as required. Facility had an emergency fire drill/evacuation drill on 7/5/24, record review.
LPA toured the facility with the Administrators. Hot water was checked at 118.2 degrees Fahrenheit. All exits were free and clear of obstruction. All exit doors had auditory alarms. Fire extinguishers, two (2), were showing fully charged, were inspected and tagged. Food supply was sufficient. All cleaners/disinfectants were locked and inaccessible to residents in care. Facility was clean and orderly. Facility had a sufficient supply of personal protective equipment (PPE), paper products, hygiene products, linens, and furnishings for resident use.
LPA is requesting the following documents be updated and submitted by 8/23/24:
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required- if no changes submit last page with date/signature of review)
Infection Control Plan (ensure to review and update as needed/required- if no changes submit last page with date/signature of review)
Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash)
Copy of Current Liability Insurance
Resident Roster

No deficiencies cited today.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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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