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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275200867
Report Date: 03/06/2022
Date Signed: 03/06/2022 04:30:03 PM


Document Has Been Signed on 03/06/2022 04:30 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,
, CA



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: 5DATE:
03/06/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Lita WilliamsTIME COMPLETED:
05:00 PM
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On 3/06/2022, Licensing Program Analyst (LPA) Jaclyn Avila conducted an unannounced complaint investigation visit and met with Lita Williams, administrator. Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95

Upon arrival at approximately 11:30 AM, LPA observed a large pumpkin outside of the facility entrance. The pumpkin obstructed the pathway of an exit door to a resident bedroom. LPA entered the facility and did not observe any staff or residents wearing face coverings. LPA was not screened for COVID 19 symptoms.

LPA met with Licensee/Administrator Lita Williams to conduct a complaint investigation. LPA requested a copy of the facility map which Lita was unable to produce. LPA requested Lita provide LPA with a tour of the facility, LPA observed the following deficiencies:

At 11:51AM, LPA toured resident's (R1) room and observed a commode blocking the exterior exit door. LPA opened the door and observed the large pumpkin obstructing the exit. The pumpkin took up half of the width of the door way.

At 11:53 AM, LPA observed cleaning supplies accessible to residents in care. The chemicals consisted of Bleach, Gain, Windex, Tide Pods, etc. These items are kept in a cabinet above the washer and dryer in a hallway that consist of 3 resident rooms. The cabinet had the ability to lock however was not secured.

At 11:57 AM, LPA observed a fire extinguisher in the hallway near the laundry room that had not been signed off as inspected monthly however it was serviced in the last year.

Cont'd on LIC 809-C
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: SHEPHERD'S INN
FACILITY NUMBER: 275200867
VISIT DATE: 03/06/2022
NARRATIVE
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At 11:57 AM, LPA observed a fire extinguisher in the hallway near the laundry room that had not been signed off as inspected monthly however it was serviced in the last year.

At 11: 59 AM LPA toured a bedroom being occupied by a resident (R2) on hospice . Below the residents bed was an open faced heater that was not screened. LPA observed a camera on the R2's dresser facing R2. LPA observed that it was plugged in with the light on. Lita stated that it was not in use due to it not being allowed. Lita then unplugged the camera. At 12:03 PM, LPA observed the corresponding monitor on a table in the dining room that was plugged in and on. The monitor has the ability to monitor auditory and visually.

At 12:01 PM, LPA requested Lita to open a cabinet that is the dining room that would be accessible to residents in care. In this cabinet, LPA observed supplements such as Collagen, Lutemax, and Magnesium. LPA observed a Coach paper bag that contained prescription medications for staff (S1).

At 12:04 PM, LPA observed razors and Clorox wipes on the kitchen counter. In a desk located across from the kitchen bar, LPA requested Lita open the top drawer as its accessible to residents in care. LPA located several kitchen knives in that drawer.

At 12:06 PM, Lita shared that she has difficulty with opening locks so she instead has used a D-shaped carabiner which hooks around the cabinet handles however does not have a locking mechanism. Lita opened this cabinet and inside were pre poured medications. LPA reviewed regulation 87465 -Incidental Medical and Dental Care-(h)The following requirements shall apply to medications which are centrally stored:(5)Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. At approximately 12:50 PM, Lita walked away to obtain documents and left a cabinet containing medications opened and accessible.

LPA requested an updated copy of the LIC 610E Emergency Disaster Plan for Residential Care Facilities for the Elderly. The most recent copy Lita could produce was from 2011. LIC 610E due by COB on 3/7/2022.

The following deficiencies were cited per Title 22 of the California Code of Regulation (See LIC 9099D or 809D). Appeal Rights were explained and provided to the facility representative listed above and an Exit Interview was conducted. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/06/2022 04:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA


FACILITY NAME: SHEPHERD'S INN
FACILITY NUMBER: 275200867

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/07/2022
Section Cited

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87307-Personal Accommodations and Services-(d) The following space and safety provisions shall apply to all facilities:(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced
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by: Based upon observation the Licensee failed to keep both the exterior and interior passage way to an emergency exit free from obstruction

This poses an immediate Health, Safety and/or Personal Rights risk to Residents in care.
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Type A
03/07/2022
Section Cited

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87309 (a)- Storage Space-Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced By:
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Based upon observation the Licensee failed to keep disinfectans and cleaning solutions stored inaccessible to residents in care

This poses an immediate Health, Safety and/or Personal Rights risk to Residents in care.
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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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 03/06/2022 04:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA


FACILITY NAME: SHEPHERD'S INN
FACILITY NUMBER: 275200867

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/07/2022
Section Cited

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87465(h)(2)-Incidental Medical and Dental Care-following requirements shall apply to medications which are centrally stored:(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees.
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This requirement is not met as evidenced by: Based upon observation and interview the Licensee failed to keep medication centrally stored and locked so that it is no accessible to 5 of 5 residents in care.

This poses an immediate Health, Safety and/or Personal Rights risk to Residents in care.
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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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4