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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603184
Report Date: 10/14/2022
Date Signed: 10/17/2022 01:19:10 PM

Document Has Been Signed on 10/17/2022 01:19 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:SHEPHERD'S ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198603184
ADMINISTRATOR:MILLER, SHELLY AFACILITY TYPE:
735
ADDRESS:600 WEST ALMOND STREETTELEPHONE:
(310) 609-2439
CITY:COMPTONSTATE: CAZIP CODE:
90220
CAPACITY: 4CENSUS: 4DATE:
10/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Shelly MillerTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Martessa Brown conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Jaqueline Boone-DSP and 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 staff toured the physical plant. There were no clients present, all were at the adult day program. Bedrooms #1 and #2 are being used as staff rooms. 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. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathroom regulations and were clean and operational. The water temperature measured 123 F degrees. 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.

LIC 809

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SHEPHERD'S ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198603184
VISIT DATE: 10/14/2022
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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 observed medication locked in cabinet and clients and staff file,

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.

Exit interview held. A copy of the report was provided to Shelly Miller, the Administrator.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
LIC809 (FAS) - (06/04)
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