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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609524
Report Date: 06/01/2024
Date Signed: 06/01/2024 11:48:12 AM

Document Has Been Signed on 06/01/2024 11:48 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME:SHEPHERD HOMEFACILITY NUMBER:
197609524
ADMINISTRATOR/
DIRECTOR:		ONESMUS TAYEBWAFACILITY TYPE:
735
ADDRESS:19141 LEMAY STREETTELEPHONE:
(818) 578-5388
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 4CENSUS: 4DATE:
06/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:35 AM
MET WITH:Administrator Onesmus TayebwaTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Kimberly Ramirez conducted an unannounced Annual Inspection visit on 06/01/2024. LPA Ramirez were met by Caregiver MUHAMMAD KAYIZI and explained the purpose of the visit. Administrator Tayebwa, arrived shortly after to assist with tour. This facility is licensed as an Adult Residential Facility and is serviced by North Los Angeles Regional Center. This facility is a level 4 home. The facility is licensed to serve FOUR (4) developmentally disabled clients ages 18 and above; of which all must be ambulatory. During today’s visit, LPA Ramirez observed three (3) caregivers providing direct care and supervision to clients.

LPA OBSERVATIONS: The facility is a single-story home that contains four (4) bedrooms, two (2) client bathrooms, living room, kitchen, dining room, laundry room, backyard, and attached garage.

Front Yard: LPA Ramirez observed front yard to be free of hazards and well maintained.

Kitchen: LPA Ramirez observed appliances to be clean and in working order. LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located kitchen cabinet, to be inaccessible to four (4) out of four (4) clients in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants to be inaccessible to four (4) out of four (4) clients in care. Signs promoting hand washing were observed in this area.

Dining Room/Living room: Dining room was observed to contain one table with several chairs. The living room was observed to contain plenty of lighting. LPA Ramirez observed a fully charged fire extinguisher nearby.

SEE 809-C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 06/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: SHEPHERD HOME
FACILITY NUMBER: 197609524
VISIT DATE: 06/01/2024
NARRATIVE
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Linen Closet/Supply Closet: Observed to contain plenty linens, towels, and hygiene products.

Client Rooms 1 - 4: All clients bedrooms are private. LPA Ramirez observed all client bedrooms to contain the required linens, furnishings, and lighting.

Bathroom 1-2: Water temperature in bathroom#1 was measured at 155.4 degrees F, which is not within Title 22 regulation. Bathroom door in bathroom#1 was observed to be broken and would not stay closed shut. LPA Ramirez will issue Type A violation based on water temperature in bathroom#1. LPA Ramirez will issue Type B violation for bathroom#1 door being in disrepair. Bathroom#2 water temperature was measured at 115.6 F degrees. Both bathrooms were observed to be clean and contain grab bars near toilets.

Backyard: No large bodies of water were observed.

Emergency Drills: Last two drills were conducted on 01/20/2024 and 05/29/2024.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide and smoke detectors in hallways. Smoke detectors were observed to be operable during visit. Fully charged fire extinguishers were observed throughout the facility.

Personnel Records: Personnel records are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for two (2) out of the two (2) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for two (2) out of the two (2) personnel records reviewed. LPA Ramirez observed an Administrator’s Certificate for ONESMUS TAYEBWA which expires on 11/26/2024.

Client Records: Client files are maintained at the facility. LPA Ramirez reviewed four (4) client records. No deficiency was observed. Admissions Agreement, Medical Assessment, Consent Forms, Appraisal and Needs and Services plan, I.D and Emergency Information, TB Test, Centrally Stored Medication Record, and Personal Rights Form.

Infection Control Plan: LPA Ramirez reviewed approved infection control plan and emergency disaster plan.

Two (2) deficiencies were cited today. Exit interview was conducted. A copy of this report, 809-D, and appeals rights was provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/01/2024 11:48 AM - It Cannot Be Edited


Created By: Kimberly Ramirez On 06/01/2024 at 11:06 AM
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
,
, CA

FACILITY NAME: SHEPHERD HOME
FACILITY NUMBER: 197609524

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 4 out of 4 consumers, and/or staff and visitors, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2024
Plan of Correction
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Licensee lowered water temperature during visit. Licensee will maintain a water temperature log for the next 3 calendar days and record water temperature in all grooming areas every 12 hours. Proof of log must be sent to LPA Ramirez via email by 06/04/2024.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 06/01/2024 11:48 AM - It Cannot Be Edited


Created By: Kimberly Ramirez On 06/01/2024 at 11:06 AM
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
,
, CA

FACILITY NAME: SHEPHERD HOME
FACILITY NUMBER: 197609524

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, bathroom #1 door would not stay shut when LPA Ramirez attempted to close the door for privacy, the licensee did not comply with the section cited above in 4 out of 4 consumers, and/or staff and visitors, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/15/2024
Plan of Correction
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Licensee will repair door and send invoice and picture proof to LPA Ramirez via email.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2024


LIC809 (FAS) - (06/04)
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