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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601344
Report Date: 11/23/2021
Date Signed: 11/23/2021 10:33:57 PM

Document Has Been Signed on 11/23/2021 10:33 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SHEPARD HOMEFACILITY NUMBER:
198601344
ADMINISTRATOR:LUCILA C. COXFACILITY TYPE:
735
ADDRESS:10625 POTTER STTELEPHONE:
(562) 863-4869
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 3CENSUS: 3DATE:
11/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Lucila CoxTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Nicol Wesley conducted an unannounced Required 1 year inspection at the facility and met with Administrator Lucila Cox and explained the purpose for todays visit. Prior to the visit LPA Wesley conducted a risk assessment for on-site inspections. The facility phone number is 562 863 4869.

The facility consist of three resident bedrooms, two bathrooms, living room, dining room, kitchen. laundry room, covered patio in the back yard, an unattached garage(storage).

During the visit the Infection control domain was used and the following areas were observed/inspected: The facility had all postings at the front entrance, bathrooms, and throughout the facility. Hand sanitizing gel and masks were located at the entry of each room. A Pre screening area with PPE supplies was observed upon entry into the facility. Water was tested and measured 106.2 F. The Mitigation plan was reviewed and approved on 04/17/21. Administrator certificate for Lucila C Cox #6001056735 expires on 07/09/2023.

There are no deficiencies cited. Exit interview conducted.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Nicol Wesley
LICENSING EVALUATOR SIGNATURE: DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/23/2021
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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