198601923-12-3-2024-28-AS-NGAA-DBM2E2-20241203161914

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601923
Report Date: 12/03/2024
Date Signed: 12/03/2024 04:19:30 PM

Document Has Been Signed on 12/03/2024 04:19 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/ DIRECTOR:	MILA LAFIGUERA		FACILITY TYPE:	735
ADDRESS:	18882 DAMASCO ST.		TELEPHONE:	(626) 964-8633
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91792
CAPACITY: 6		CENSUS: 5	DATE:	12/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:03 PM
MET WITH:	Lilibeth Esguerra- Nuckolls, Assistant Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:20 PM

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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit. The purpose of the visit was explained to Administrator Mila Lafiguera. Assistant Administrator Lilibeth Esguerra- Nuckolls arrived shortly after. The facility is licensed as an Adult Residential Facility for six (6) [2 non-ambulatory & 4 ambulatory] developmentally disabled adults ages 60 and over. The facility is licensed as a level 4A ARF vendored by San Gabriel/Pomona Regional Center. The following 12 Care Compliance and Regulatory Enforcement (CARE) tool domains were utilized during the inspection.

The following were observed/inspected:

Infection Control: The Infection Control Plan was reviewed. The facility has sufficient supply of Personal Protective Equipment (PPEs).

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. The facility has one (1) fully charged fire extinguisher and a fire pull alarm in the living room. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. The facility has a 1st Aid Kit and Manual.

Cleaning supplies, knives, and toxic substances were observed unlocked and accessible to residents under the kitchen sink. It was determined the locking mechanism is faulty. A repairman arrived during the visit.

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 7/9/2025.

Staffing: A total of 7 staff members provide care and supervision to the clients.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

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: 12/03/2024

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Personnel Records/Staff Training: Administrator certificate expires 1/15/2025. Staff have criminal background clearance and training. Five (5) staff files were reviewed. Proof of staff training, health and TB clearance, and 1st Aid/CPR training are on file. Proof of in-service training that includes HCBS Final rule was observed in staff files. No proof of required RCFE training requirements due to Age Exceptions in place was observed. A citation was issued.

Client Rights/Information: Physician orders, and personal rights were reviewed in client files.

Client Records/Incident Reports: Four (4) resident files were reviewed. 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. HCBS Tenant/Landlord Agreements are in files.

*Three (3) residents are over the age of 59. Age Exceptions were approved 11/22/2023.

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. One (1) resident has a modified diet.

Health Related Services: Residents are assisted with self administration of prescription and non-prescription medications. Centrally stored resident medication records were reviewed and 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: A posted LIC 610D Emergency Disaster Plan was observed. 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 6/15/2024.

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: 12/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/03/2024 04:19 PM - It Cannot Be Edited

Created By: Noemi Galarza On 12/03/2024 at 03:32 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: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)

Personnel Requirements – General . All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. 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 there are currently 3 residents with Age Exceptions that were approved 11/22/2023, but no proof of initial 10 hours of RCFE training and four hours annually thereafter was completed, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/14/2025
	Plan of Correction
1 2 3 4	Administrator shalll train all staff in aging process and physical limitations and special needs of the elderly. Submit training logs that include topic, hours, and staff signatures.

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: 12/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 12/03/2024 04:19 PM - It Cannot Be Edited

Created By: Noemi Galarza On 12/03/2024 at 03:49 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: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that the cabinet underneath the kitchen sink was unlocked; it contained disinfectants, cleaning solutions, and knives, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/03/2024
	Plan of Correction
1 2 3 4	Staff stated that the locking mechanism is at times faulity. It was immediately locked. Additionally, facility repairman arrived during the visit. *Citation was cleared.

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: 12/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC809 (FAS) - (06/04)

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