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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601923
Report Date: 11/17/2022
Date Signed: 11/17/2022 03:20:49 PM

Document Has Been Signed on 11/17/2022 03:20 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:SHEPHERDS HOMEFACILITY NUMBER:
198601923
ADMINISTRATOR:MILA LAFIGUERAFACILITY TYPE:
735
ADDRESS:18882 DAMASCO ST.TELEPHONE:
(626) 964-8633
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 6CENSUS: 5DATE:
11/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Lilibeth Nuckolls, LicenseeTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Administrator Mila LaFiguera and explained the purpose of the visit. Licensee Lilibeth Nuckolls arrived later. There are five (5) level 4A developmentally disabled clients in the home; one (1) resident is non-ambulatory. The facility is a single story home located in a residential neighborhood. It consists of 3 client bedrooms, 2 office rooms, 2 bathrooms, kitchen/dining room, living room, outdoor patio, and attached garage. The last fire/emergency drill was conducted on June 18, 2022. Administrator certificate expires 11/18/2023.
OBSERVATIONS:
  • The interior and exterior physical plant was inspected. The facility is equipped with a fire pull alarm system. Smoke and carbon monoxide detectors were tested and operational.
  • COVID-19 Infection Control Practices and signs that promote hand washing, cough/sneeze etiquette, and physical distancing were observed in the entrance, common areas, hallways, bathrooms and client rooms. There is a screening station at the entrance of the facility to screen visitors.
  • Room #3 is designated as a COVID-19 isolation room if needed.
  • A posted Emergency Disaster Plan was observed.
  • Four (4) centrally stored client medication records were reviewed. Medications are documented properly and given as prescribed.
  • Staff were observed wearing mask. Clients do not wear masks due to disability exemption.
  • The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food.
  • Water temperature was within normal limits 105 degrees Fahrenheit (40.5 degrees C) and not more than 120 degrees Fahrenheit (48.8 degrees C).
  • Facility has an adequate 30-day+ supply of Personal Protective Equipment (PPEs).
  • All staff have fingerprint clearances.
  • The facility submitted a COVID-19 Mitigation Plan.
  • An Infection Control Plan (ICP) has not been submitted. Submit the ICP as soon as possible A technical assistance advisory note was issued.
No deficiencies were cited.
Exit interview was conducted with Licensee Lilibeth Nuckolls. A copy of the report was issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
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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