198603184-9-24-2021-11-AS-MBRN-C76UB3-20210924152541

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603184
Report Date: 09/24/2021
Date Signed: 09/24/2021 06:10:09 PM

Document Has Been Signed on 09/24/2021 06:10 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	SHEPHERD'S ADULT RESIDENTIAL FACILITY		FACILITY NUMBER:	198603184
ADMINISTRATOR:	MILLER, SHELLY A		FACILITY TYPE:	735
ADDRESS:	600 WEST ALMOND STREET		TELEPHONE:	(310) 609-2439
CITY:	COMPTON	STATE: CA	ZIP CODE:	90220
CAPACITY: 4		CENSUS: 4	DATE:	09/24/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:38 PM
MET WITH:	Shelly Miller		TIME COMPLETED:	03:30 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) Martessa Brown conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Shelly Miller, the Administrator and the purpose of today’s visit was explained. The facility is licensed to serve 4 developmentally disabled clients (age 18-59). There are currently (4) South Central Regional Center clients in placement. All (4) clients are ambulatory. The facility is a two-story structure located in a residential neighborhood. It consists of the following: 4 bedrooms, 2 bathrooms, family room/dining room, kitchen, living room, indoor and outdoor with attached shaded cover area, laundry room is located in the attached garage. LPA and Administrator toured the physical plant. There was 2 residents at the home during time of visit and the other 2 residents were at the adult day facility.There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for Client personal belongings was observed. LIC 809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021

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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SHEPHERD'S ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 198603184
	VISIT DATE: 09/24/2021

NARRATIVE

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Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 120 F and bathroom #2 105 F. A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there was enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations (Located in common areas and restrooms). LPA observed administrator was wearing face covering, Resident will go to surge facility for isolate or Covid-19 positive. LPA observed the facility will need to have 30-day supply of Personal Protective Equipment (PPE).

LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit there were no deficiencies observed.

Exit interview held. A copy of the report was provided to Shelly, the Administrator.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021

LIC809 (FAS) - (06/04)

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