<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601344
Report Date: 07/12/2024
Date Signed: 07/12/2024 02:21:55 PM

Document Has Been Signed on 07/12/2024 02:21 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SHEPARD HOMEFACILITY NUMBER:
198601344
ADMINISTRATOR/
DIRECTOR:		LUCILA C. COXFACILITY TYPE:
735
ADDRESS:10625 POTTER STTELEPHONE:
(562) 863-4869
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 3CENSUS: 3DATE:
07/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:16 PM
MET WITH:House Manager, Loridelle JameroTIME VISIT/
INSPECTION COMPLETED:
02:45 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) S Vaid 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 House Manager Loridelle Jamero and explained the purpose for 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.
During today's visit, LPA Vaid 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:
Single 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. 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 107.4*F in bathroom# 1 and 110.2*F in bathroom# 2 and 109.6* F in the kitchen 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.
Continued on LIC 809C.. next page..
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2024
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SHEPARD HOME
FACILITY NUMBER: 198601344
VISIT DATE: 07/12/2024
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
26
27
28
29
30
31
32
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. Earthquake and fire drills are held every month last drill was conducted 06/06/24. (2) client files were reviewed and had the required documents. (3) staff files were reviewed and had the required documents. Client #1 and #3 are non verbal, client # 2 is at day program are therefore not interviewed.

No deficiencies were noted on today's visit, conducted exit interview with House Manager Loridelle Jamero and provided a copy of this report.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2