198601344-8-30-2023-28-AS-VMAO-CV7S32-20230830133024

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601344
Report Date: 08/30/2023
Date Signed: 08/30/2023 01:30:35 PM

Document Has Been Signed on 08/30/2023 01:30 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 HOME		FACILITY NUMBER:	198601344
ADMINISTRATOR:	LUCILA C. COX		FACILITY TYPE:	735
ADDRESS:	10625 POTTER ST		TELEPHONE:	(562) 863-4869
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY: 3		CENSUS: 2	DATE:	08/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Lucila Cox- Licensee/Administator		TIME COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required annual inspection, using the Care Compliance and Regulatory Enforcement (CARE) Tool to evaluate the facility. LPA met with Direct Support Professional, Loridelle Jamero and explained the purpose fot the visit. Licensee/Administrator, Lucila Cox arrived shortly after to assist with the visit. The facility is licensed to serve (3) developmentally disabled adults, ages 18-59, of which (2) may be non-ambulatory. The facility is a single-story home, located in a residential area. The home consists of a living room, (3) client bedrooms, (2) client bathrooms, a kitchen, dining room, attached garage, and shaded patio. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention. During today's visit, LPA Maldonado obtained a copy of the client and staff roster, and conducted a tour of the physical plant with assistance of DSP, Loridelle Jamero. The following was observed: One central entry point for universal entry screening Mitigation Plan and Infection Control Plan approved and in place Sufficient PPE stored for 30-days and readily available for use, throughout the home and stored in the garage Physical plant inside and outside is clean, sanitary and in good repair All walkways and pathways observed to be free of obstruction/hazards All client bedrooms had the required furniture and the bedding had the required linens (Report Continued on LIC809-C...)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SHEPARD HOME	FACILITY NUMBER: 198601344
	VISIT DATE: 08/30/2023

NARRATIVE

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Additional linens were observed in a linen closet in the hallway, inspected and in good repair.
Cleaning supplies and toxins were observed locked and inaccessible in a close in the hallway and in the garage
Each bathroom was equipped with a toilet, shower, and wash basin. All operational and in good repair
The water temperature was tested and measured at 118.9*F in bathroom# 1 and 119.8*F in bathroom# 2 and is in compliance
Sharps and knives were stored inaccessible in a kitchen drawer next to the dishwasher
Food supplies was inspected and observed to have the required 2-day perishables and 7-day non-perishables- food was sufficient for amount of clients in care
The first aid kit was inspected and had the required items/First Aid Manual available
The facility had all required posting posted throughout
The washing machine and dryer were observed in the garage and clean and operational at the time of the visit
The smoke/carbon monoxide detectors were tested and operational
(2) client files were reviewed and had the required documents
(3) staff files were reviewed and had the required documents
At 11:26AM, LPA reviewed (2) client's medications and observed that (1) of (2) client's medication was not dispensed on 8/23/23 and was still in the bubble pack. LPA inquired with DSP Loridelle, who stated it appeared to be an error and it was not documented.

Per California Code of Regulations, Title 22, deficiencies were observed and will be cited on the LIC809-D.

An exit interview was conducted with Licensee/Administrator Lucila Cox and copy of the report and appeal rights were provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/30/2023 01:30 PM - It Cannot Be Edited

Created By: Valeria Maldonado On 08/30/2023 at 01:14 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: 08/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80075(b)(5)(B)

Health-Related Services

(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observatio, interview, and record review, the licensee did not comply with the section cited above in 1 out of 2 client's medications not being administered as prescribed, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/31/2023
	Plan of Correction
1 2 3 4	The licensee will conduct medication training for direct care staff and provide a copy of the training material and sign in sheet for participants via email to the LPA by the POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Fernando Fierros

LICENSING EVALUATOR NAME:

Valeria Maldonado

LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

LIC809 (FAS) - (06/04)

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