019200980-10-20-2022-15-AS-BFOG-CP5SWG-20230217131418

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200980
Report Date: 10/20/2022
Date Signed: 10/20/2022 02:46:37 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/14/2022 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20220314112937

FACILITY NAME:	SHEPHERD HOUSE		FACILITY NUMBER:	019200980
ADMINISTRATOR:	KHAN, DOREEN		FACILITY TYPE:	735
ADDRESS:	300 SHEPHERD AVE		TELEPHONE:	(510) 303-0553
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94544
CAPACITY:	4	CENSUS: 4	DATE:	10/20/2022
		UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	Doreen Khan/Administrator		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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-Facility failed to comply with restraining order.

-Facility failed to administer resident’s medication as prescribed.

-Facility staff speak inappropriately to resident.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Alicia Delmundo and Lori Alexander arrived unannounced to continue the investigation of the above allegations and close the complaint. LPA met with Doreen Khan, administrator.

During the course of investigation, LPA Delmundo reviewed residents' (R1, R2., R3 and R4) files. Interviews were conducted and copies of following documents were obtained: RCEB Placement Informatoon; Physician's Report; Quarterly Progress Report; lists of medications; Medication Administration Records; LIC622 Centrally Stored Medication and Destruction Records, Individual Program Plan (IPP); Addendum to IPP; Individual Service Plan; Behavioral Assessment; Appraisal/Needs and Services Plan; Client Confidential Information with Code; Special Incident Reports

.....continued on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20220314112937

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SHEPHERD HOUSE	FACILITY NUMBER: 019200980
	VISIT DATE: 10/20/2022

NARRATIVE

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Allegation: Facility failed to comply with restraining order.
It was alleged that R1 has a restraining order against an individual (AA) and facility is not complying for allowing R1 to go out with AA. Administrator stated that AA never comes to the facility and contacts R1 via phone call. Administrator indicated that R1 has access to the facility telephone and that R1 can leave the facility unassisted. R1 stated that she has a personal relationship with AA. Review of R1's record revealed R1 can leave the facility unassisted.

Allegation: Facility failed to administer resident’s (R1) medication as prescribed.
It was alleged that R1 has a prescribed medication and facility failed to order a refill for this particular medication. It was further alleged that R1 had bleeding at the buttocks as a resul of facility failing to administer the medication as prescribed. Staff S1 was interviewed who indicated at the time of alleged incident of bleeding, R1 was checked and there was no sign of rupture. S1 stated that R1 can communicate needs and that the particular medication is prescribed on as needed (PRN) basis. R1 indicated she missed her medications when she is out in the community. R1 also stated that she's given the PRN medications when she ask for it. Administrator stated the facility never run out medications. Review of LIC622 Centrally Stored Medication and Destruction Records and Medication Administration Records confirmed S1, R1 and administrator's statements.

Allegation: Facility staff speak inappropriately to resident.
It was alleged that staff speak inappropriately to R1. R1 was interviewed and indicated that staff yelled at her. Residents (R2, R3 and R4) indicated no staff has yelled and/or speak inappropriately at them nor to R1. S1 denied yelling at R1. Administrator indicated that S1 coaches R1 and that both talk loud.

Based on information gathered, the allegations are unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

No deficiency cited.

Exit interview conducted and copy of report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

LIC9099 (FAS) - (06/04)

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