197609524-11-29-2023-31-AS-APAA-CY2SME-20231129125949

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609524
Report Date: 11/29/2023
Date Signed: 11/29/2023 01:00:18 PM

Document Has Been Signed on 11/29/2023 01:00 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 HOME		FACILITY NUMBER:	197609524
ADMINISTRATOR:	ONESMUS TAYEBWA		FACILITY TYPE:	735
ADDRESS:	19141 LEMAY STREET		TELEPHONE:	(818) 578-5388
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY: 4		CENSUS: 4	DATE:	11/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Amanya Herbert, Administrator		TIME COMPLETED:	01:30 PM

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At 10:40am Licensing Program Analyst (LPA), Angela Panushkina, conducted an unannounced annual inspection at the facility mentioned above. LPA was greeted by the Staff #1 (S1), Bruce Nkwasibwe, who granted access to the facility. Administrator arrived shortly after, and LPA explained the reason for the visit. Physical tour was conducted with S1 and LPA observed the following:

Kitchen: At approximately, 10:50am LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives, sharps and chemicals observed to be locked under the kitchen sink and inaccessible to clients in care. Fire extinguisher in the kitchen was last services on 07/20/23.

Medications: At approximately, 10:55am LPA observed medications are centrally stored and locked in the vertical 4-drawer, black cabinet by the kitchen.

Bedrooms: There are four (4) bedrooms designated for clients use with sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens.

Bathrooms: At 11:00am LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and client's bathroom had non-skid mat. LPA observed appropriate hand washing signs posted in each bathroom. All trash cans in bathrooms had fitted lids to protect from cross contamination. Hot water temperature measured at 119.8°F.

Common Areas: The facility maintains a comfortable temperature at 68°F. The living room and dining area appeared clean and were properly furnished. The living room has a television and comfortable furniture. No obstructions and or tripping hazards throughout the facility.

Continue on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

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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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: 11/29/2023

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Outside areas: At approximately, 11:10am LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. Laundry is located outside and LPA observed all detergents locked and inaccessible to clients in care. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients. There are no bodies of water.

Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 11:25am they were tested and observed to be operational.

Between 11:30am to 12:10pm, LPA reviewed records of four (4) clients and two (2) staff. Resident and staff records appeared to be complete and updated. LPA collected Certificate of Liability Insurance and LIC500.

No citations issued during this visit.

Exit interview conducted. Copy of report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

LIC809 (FAS) - (06/04)

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