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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609524
Report Date: 03/16/2022
Date Signed: 03/16/2022 04:44:24 PM

Document Has Been Signed on 03/16/2022 04:44 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:SHEPHERD HOMEFACILITY NUMBER:
197609524
ADMINISTRATOR:ONESMUS TAYEBWAFACILITY TYPE:
735
ADDRESS:19141 LEMAY STREETTELEPHONE:
(818) 578-5388
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 4CENSUS: 4DATE:
03/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Onesmus Tayebwa TIME COMPLETED:
04:50 PM
NARRATIVE
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At approximately 2:15 PM on 03/16/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with staff and later Administrator and disclosed the reason for the visit. LPA and staff toured the facility inside and out.

Census: 4 consumers, 3 staff

The facility is a single-story building with 4 bedrooms, 2 bathrooms, a living room, office space, dining room, kitchen, garage, and a back yard. The facility has auditory devices on all exit doors. The facility has a fire clearance for 4 ambulatory consumers.

Upon entry, LPA was screened for symptoms of COVID-19 and temperature checked. Staff recorded LPA name and temperature. The facility’s screening station contained surgical masks, N95 masks, and hand sanitizer. All staff were wearing surgical or N95 masks. Postings for personal rights, grievance procedure, confidential complaints, abuse reporting instructions, facility license, and Ombudsman contact were visible at the front. LPA also observed signs for the facility’s COVID precautions, activity schedule, and a monthly menu.

Bedrooms: All bedrooms were private bedrooms, and all bedrooms were clean and free from debris. Bedroom #1 and Bedroom #3 had windows without screens. The windows in both rooms had locks which restricted the window from opening or closing further. The screen to the window of Bedroom #3 was observed on the ground outside. Bedroom #3 also had black padding on the walls. All bedrooms contained a chair, nightstand, lamp, dresser, adequate storage, and beds with adequate bedding available.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SHEPHERD HOME
FACILITY NUMBER: 197609524
VISIT DATE: 03/16/2022
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Bathrooms: Bathroom #1 was located near the front of the facility, and Bathroom #2 was private to Bedroom #4. LPA observed non-skid mats, fully stocked liquid soap, handwashing instruction signs, and trash cans in both bathrooms. Staff provide paper towels to consumers as needed. LPA recommended a trash can with a lid for infection control purposes.

Common Areas: LPA observed a closet with hygiene supplies, paper supplies, blankets, and linens. Furniture was arranged to accommodate social distancing. The indoor temperature was measured at 75 degrees Fahrenheit. 2 consumers were observed watching television in the living room during the visit.

Kitchen: In the kitchen, LPA observed chemicals and cleaning supplies locked under the sink. Sharp objects were locked in a separate lockbox under the sink. The keys for the locks were stored in an accessible drawer, so LPA suggested staff keep the keys in an inaccessible location. Medications were locked in a cabinet near the kitchen. The kitchen had an adequate supply of perishable and non-perishable food. Between the kitchen and the laundry area hung a fully charged fire extinguisher.

Laundry: The facility had a laundry area outside of the kitchen towards the back yard. The laundry area had an operable washer and dryer with detergents locked in a cabinet.

Outdoors: LPA toured the back yard and observed a wood deck, stairs with sturdy handrails, an artificial grass lawn, furniture which was shaded by an umbrella, and 2 emergency exit paths. All paths were well maintained and free from obstructions or hazards.

Safety: LPA tested smoke detectors and a carbon monoxide detector, and both were functioning appropriately. At approximately 2:40 PM, LPA measured water temperature in the shared bathroom to be 111.7 degrees Fahrenheit. All emergency exit paths were unlocked with inward facing, self-closing latches.

All floors, ceilings, walls, and furniture were clean and in good condition.

During today's visit, facility was not in compliance with Title 22 Regulations and one citation was issued.



Exit interview conducted, citation issued, appeal rights discussed, and copy of the report issued.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
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Document Has Been Signed on 03/16/2022 04:44 PM - It Cannot Be Edited


Created By: Nicholas Reed On 03/16/2022 at 04:24 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SHEPHERD HOME

FACILITY NUMBER: 197609524

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 03/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
87303 Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 3 out of approximately 15 windows which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/16/2022
Plan of Correction
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Licensee will reapply the window screens on all windows and maintain them in good condition. Licensee will apply an adhesive to the window screens to secure them. Licensee will send a photo of the completed tasks. If consumers break the screens again, Licensee will report the incident to Community Care Licensing.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Cassandra Harris
LICENSING EVALUATOR NAME:Nicholas Reed
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022


LIC809 (FAS) - (06/04)
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