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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803954
Report Date: 02/24/2025
Date Signed: 02/24/2025 04:33:27 PM

Document Has Been Signed on 02/24/2025 04:33 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 OF SANTA ROSAFACILITY NUMBER:
496803954
ADMINISTRATOR/
DIRECTOR:
ORTEGA, MANUEL C. JR.FACILITY TYPE:
740
ADDRESS:2028 DENNIS LANETELEPHONE:
(707) 205-6907
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 6CENSUS: 6DATE:
02/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:40 PM
MET WITH:Manuel Ortega-AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analysts (LPAs) Alviso and Contreras conducted a Required- 1 Year inspection, at about 3:40pm on 2/24/25, and met with Manuel and Joy Ortega. Currently there are 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. Facility has a required emergency disaster plan. Facility has a required infection control plan.

The LPAs toured the facility with Licensee Joy and Manuel. Hot water was checked at 109.2 degrees Fahrenheit. All medications were locked up and inaccessible to residents in care, and staff/others that don't handle resident medications. All disinfectants/cleaners were locked up and inaccessible to residents in care. Facility had a sufficient supply of emergency supplies, including food and water, to meet the 72-hour shelter in place requirements. Carbon monoxide detector was working properly during the inspection. All exit doors had auditory alarms on them; All auditory alarms were working properly.

This annual will be continued by the LPAs at a later date.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2025
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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