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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601344
Report Date: 02/10/2023
Date Signed: 02/13/2023 08:56:46 AM

Document Has Been Signed on 02/13/2023 08:56 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
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: 2DATE:
02/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Lucila CoxTIME COMPLETED:
01:45 PM
NARRATIVE
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LPA Angelica Rea conducted an unannounced visit for the purpose of conducting the required annual inspection. On today's visit LPA met with Administrator, Lucila Cox who assisted with the visit.

LPA Rea discussed infection control practices with Ms. Cox, toured the facility inside and out, reviewed food supply, staff files, and reviewed resident medications.

Bedrooms have the required furniture including bedframes, dressers, lamps and chairs. Beds have the required linen and the linen is in good condition. Passageways and exits are free of obstruction. The front and backyard are well maintained. The resident bathroom is clean and have the required grab bars in the shower and near the toilets. Showers also have non-skid materials. The hot water temperature measured at 134 degrees F in the kitchen sink, and 127 degrees F in (2) bathroom sinks. The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. There are smoke detectors & carbon monoxide detector were tested and operational. LPA observed a sufficient supply of PPE. Infection control signs were observed throughout the facility.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were deficiencies observed during the visit. Deficiencies on 809-D. Exit interview conducted, copy of report provided, and appeal rights provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2023
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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Document Has Been Signed on 02/13/2023 08:56 AM - It Cannot Be Edited


Created By: Angelica Rea On 02/10/2023 at 01:11 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SHEPARD HOME
FACILITY NUMBER: 198601344

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)


This requirement is not met as evidenced by: LPA Rea observed that the water temperature measured 134 degrees F in kitchen sink, and 127 degrees F in (2) bathroom sink(s)
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 3 out of 3 water temperature measurements which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2023
Plan of Correction
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Administrator will ensure that the water temperature measures between 105 degrees F and 120 degrees F as required. Administrator will send a water temperature log for 3 days, and provide a written statement certifying that the water temperature has been corrected.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Angelica Rea
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023


LIC809 (FAS) - (06/04)
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