496803954-3-10-2026-21-AS-DALO-DS33LQ-20260310182107

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803954
Report Date: 03/10/2026
Date Signed: 03/10/2026 06:24:06 PM

Document Has Been Signed on 03/10/2026 06:24 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 ROSA		FACILITY NUMBER:	496803954
ADMINISTRATOR/ DIRECTOR:	ORTEGA, MANUEL C. JR.		FACILITY TYPE:	740
ADDRESS:	2028 DENNIS LANE		TELEPHONE:	(707) 205-6907
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY: 6		CENSUS: 6	DATE:	03/10/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:55 PM
MET WITH:	Manuel Ortega-Administrator		TIME VISIT/ INSPECTION COMPLETED:	06:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Alviso conducted a Required- 1 Year inspection, at about 1:55pm on 3/10/26, and met with Administrator Manuel Ortega. LPA observed three care staff, S3, S4,and S5, on duty upon their arrival; The staff contacted the Administrator Manuel to notify them of the LPA's arrival. Currently there are six (6)residents in care. Facility has a dementia plan of operation. There is an approved hospice waiver for four (4) residents. Fire clearance is approved for six (6) non-ambulatory, of which one may be bedridden (RM #6.) Facility has a required infection control plan. Fire extinguishers, two (3), were serviced and tagged as required. Facility has a required emergency disaster plan. . LPA reviewed six (6) resident files. All files were complete, including medication records. All medications were locked up and centrally stored, as required. LPA reviewed four (4) staff files. All staff had criminal record clearance as required. All staff have first aid certification and CPR certification. Facility had sufficient lighting in bathrooms, resident rooms, hallways, and all common areas for residents in care. The home was at a comfortable temperature during the inspection. The food supply was observed to be sufficient, in perishables and non-perishables. The facility was clean and orderly. Bathrooms had grab bars, and non-slip mats/flooring in showers for resident use. Facility had sufficient furnishings for residents' use. Facility hot water was measured at 114.8 degrees Fahrenheit. Backyard was clean and orderly, with patio/yard furnishing for resident use as wanted. Continued on LIC809C...

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/10/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 ROSA	FACILITY NUMBER: 496803954
	VISIT DATE: 03/10/2026

NARRATIVE

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LPA is requesting the following documents be updated and submitted by 4/10/26:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required-no changes submit copy of review page) If changes submit plan copy
Infection Control Plan (ensure to review and update as needed/required- no changes submit copy of review page)- If changes submit plan copy
LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash)
Current Liability Insurance
Resident Roster
Copy of current Administrator Certificate

The following deficiency was observed by the LPA during the inspection:
Upon LPA's arrival to the facility, while standing at the front door, the LPA heard a staff speaking to a resident in an inappropriate manner, speaking in a very loud irritated voice at the resident. LPA questioned staff once inside the home. In summary, staff S3 stated that they were speaking with resident R1. S3 stated that the resident was trying to go outside of the front door and this is why they were speaking that way. LPA stated they were speaking so loud and irritated at the resident, and S3 stated that it was because the resident was trying to leave that's why. LPA discussed personal rights of residents in care with the staff. Resident R1 needs redirection by staff and/or the staff to follow the resident out and redirect them back inside the facility. Staff are not to raise their voice at the resident and/or yell at them. This deficiency will be cited, 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities-In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs, see LIC809D.

California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited:
Failure to correct deficiencies as required may result in civil penalties being assessed.
Exit interview conducted with the Administrator Manuel Ortega.
Appeal Rights provided with LIC809 report.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/10/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/10/2026 06:24 PM - It Cannot Be Edited

Created By: Dina Alviso On 03/10/2026 at 05:44 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SHILOH GREEN MANOR OF SANTA ROSA	FACILITY NUMBER: 496803954
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468.2(a)(4)

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities-In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA heard a staff speaking to a resident in an inappropriate manner, speaking in a very loud irritated voice at the resident. Staff S3 stated that they were speaking with resident R1. S3 stated that the resident was trying to go outside of the front door and this is why they were speaking that way;S3 stated that it was because the resident was trying to leave that's why. LPA discussed personal rights of residents in care with the staff. Resident R1 needs redirection by staff and/or the staff to follow the resident out and redirect them back inside the facility. Staff are not to raise their voice at the resident and/or yell at them. , the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/25/2026
	Plan of Correction
1 2 3 4	Licensee/Administrator to hold an in-service training with all staff, including S3. Review care plan of R1 with all care staff and ensure that staff are trained in meeting all R1's needs, as well as all residents in care. Submit proof of training by 3/25/26, with a plan of ensuring compliance with personal rights of all residents in care. POC due 3/25/26.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:

	Dina Alviso
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/10/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026

LIC809 (FAS) - (06/04)

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