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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275200867
Report Date: 12/14/2020
Date Signed: 12/22/2020 09:38:54 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:SHEPHERD'S INNFACILITY NUMBER:
275200867
ADMINISTRATOR:WILLIAMS, LITA P.FACILITY TYPE:
740
ADDRESS:11899 CYPRESS CIRCLETELEPHONE:
(831) 632-2200
CITY:CASTROVILLESTATE: CAZIP CODE:
95012
CAPACITY:6CENSUS: 4DATE:
12/14/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Lita WilliamsTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted a Technical Assist (TA) Visit via FaceTime platform with LIta Williams Licensee/ Administrator and Emma Erickson Health Facility Evaluator Nurse (HFEN), California Department of Public Health. The purpose of the visit was to provide technical assistance For Infection Prevention and Control guidelines for Adult and Senior Care facilities. LPA conducted a virtual tour of the facility. LPA and HFEN review the facility policies and procedures to include screening, disinfecting, staffing, training, emergency medical care, PPE supplies and usage and resident activities.

Informational Links and websites were provided to include Tying the Face Mask, PPE Burn Calculator, PPE Eye Protection, UCSF Donning/Doffing PPE, Seal Check for N95 Mask, Return to Work, Cleaning, Testing and Holiday Guidance.

Report reviewed with Lita Williams and copy emailed for signature purposes.
SUPERVISOR'S NAME: George NwaforTELEPHONE: (650) 269-7419
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE:
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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