198601923-10-13-2023-28-AS-NGAA-CWKSEH-20231013134847

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601923
Report Date: 10/13/2023
Date Signed: 10/13/2023 01:48:57 PM

Document Has Been Signed on 10/13/2023 01:48 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 HOME		FACILITY NUMBER:	198601923
ADMINISTRATOR:	MILA LAFIGUERA		FACILITY TYPE:	735
ADDRESS:	18882 DAMASCO ST.		TELEPHONE:	(626) 964-8633
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91792
CAPACITY: 6		CENSUS: 6	DATE:	10/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:38 AM
MET WITH:	Lillibeth Esguerra- Nuckolls, Assistant Administrator		TIME COMPLETED:	01:50 PM

NARRATIVE

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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Assistant Administrator Lilibeth Esguerra-Nuckolls. There are six (6) level 4A developmentally disabled adults; of which two (2) may be non-ambulatory. The facility is licensed for clients 18-59 years old. However, there are four (4) residents over the age of 60, which exceeds 50% of allowable residents over the age of 60. The facility is vendored by San Gabriel/Pomona Regional Center.

Infection Control:

Infection control practices and Personal Protective Equipment (PPEs) were observed. Infection Control Plan and COVID-19 Mitigation Plan and Monkey Pox Plan were reviewed.

Physical Plant/Environment Safety:

The facility is a single story home located in a residential neighborhood. It consists of 3 resident bedrooms, 1 office room, 1 staff room, 2 bathrooms, kitchen, dining room, living room, outdoor patio, and an attached garage with laundry area.

The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Electrically hard wired smoke and carbon monoxide detectors were tested and are operational. There is one (1) fire extinguisher in the kitchen.

Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.

****Report narrative continues next page.*****

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

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: SHEPHERDS HOME	FACILITY NUMBER: 198601923
	VISIT DATE: 10/13/2023

NARRATIVE

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Operational Requirements:

Fire clearance is approved for four (4) ambulatory and two (2) non-ambulatory residents.
Care and supervision to meet the clients needs was observed. Special equipment and supplies are not used by residents.
The Surety Bond is current with expiration date of 7/10/2024.

Staffing:

A total of 6 staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

Administrator certificate expires 7/7/2024.
Four (4) staff files were reviewed. Personnel record, Criminal Record Clearance, health screening/TB clearance, training, zero-tolerance policy, and 1st Aid/CPR was on file.

Client Rights/Information:

Physician orders, and personal rights were reviewed in client files.

Client Records/Incident Reports:

Six (6) resident files containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, IPP reports, personal rights, medical consent, nutritional assessments, Personal & Incidental (P & I) monies/records, and Medication Administration Records were reviewed.

***NOTE: Four (4) out of six (6) residents are over the age of 59. There are no Age Exceptions in place. A citation was issued. Licensee shall submit Age Exception documents to CCL.

Food Service:

The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.
There are no physician orders for modified diets.

See next page.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

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: SHEPHERDS HOME	FACILITY NUMBER: 198601923
	VISIT DATE: 10/13/2023

NARRATIVE

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Health Related Services:

Residents are assisted with self administration of prescription and non-prescription medications.
All resident PM medications stored in a pill box were observed in an unlocked kitchen drawer. A citation was issued.
Centrally stored resident medication records were reviewed. All other medications were observed in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions. 30-Day supply of medications were observed.

Incident Medical and Dental:

All residents have a Needs and Services Plan, Physician Reports, and COVID-19 vaccination cards on file.

Disaster Preparedness, and Emergency Intervention:

LIC 610D Emergency Disaster Plan that contains emergency evacuation information has been developed. The plan shall be reviewed annually, updated as necessary, and maintained on file at the facility.
First Aid Kit and Manual were observed.
The last emergency drill was conducted on June 22, 2023.

Emergency Intervention:

No manual restraints or seclusion are used with clients in care.

Per Title 22, California Code of Regulations, deficiencies were cited.

Exit interview conducted with Administrator Lilibeth Esguerra-Nuckolls A copy of the report and appeal rights were issued.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/17/2023 02:23 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/17/2023 02:15 PM

Created By: Noemi Galarza On 10/13/2023 at 01:20 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SHEPHERDS HOME	FACILITY NUMBER: 198601923
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80075(k)(1)

Health-Related Services

(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that all resident PM medications stored in a pill box were observed in an unlocked kitchen drawer, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/14/2023
	Plan of Correction
1 2 3 4	Administrator shall conduct staff training and submit proof of staff training.

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:

Lisa Hicks

LICENSING EVALUATOR NAME:

Noemi Galarza

LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 10/13/2023 01:48 PM - It Cannot Be Edited

Created By: Noemi Galarza On 10/13/2023 at 01:21 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: SHEPHERDS HOME	FACILITY NUMBER: 198601923
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85068.4(g)

Acceptance and Retention Limitations. If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients, or 25 percent of the census in facilities with a capacity over six, the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section above in that there are a total of 4 residents over the age of 59 [ages 79, 69, 66, 61], and an Exception Waiver for clients is not in place. The census exceeds 50% of allowable residents over the age of 60, which poses/posed a potential health, safety or personal rights risk to persons in care
	POC Due Date: 11/10/2023
	Plan of Correction
1 2 3 4	Administrator shall submit Age Exception requests for R1, R2, R3, & R4 by POC due date, and/or two of the clients shall be relocated. If an extension is required submit a written request by the due date.

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:

Noemi Galarza

LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

LIC809 (FAS) - (06/04)

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