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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 275200867
Report Date: 03/06/2022
Date Signed: 03/06/2022 04:31:30 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/01/2021 and conducted by Evaluator Jaclyn Avila
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20211001124427
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
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Lita WilliamsTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Facility failed to provide refund.
INVESTIGATION FINDINGS:
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On 3/06/2022, Licensing Program Analyst (LPA) Jaclyn Avila conducted an unannounced complaint investigation visit regarding the above allegations, and met with Lita Williams Administrator/Licensee. 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.

California Department of Social Services (CDSS) Community Care Licensing (CCL) has investigated this complaint and found the allegation to be unfounded. This department has reviewed the admission agreement signed by both licensee and power of attorney dated 05/21/2020. The admission agreement requires a 30 day notice from the resident (R1) and/or responsible party. In this case the responsible party paid the agreed upon amount for the month of September 2021 and gave a 30 day notice on August 31st, 2021. Responsible party then moved and discharged the resident from the facility on September 3rd, 2021. At the time of R1's death, the decedent was no longer a resident of Shepherd's Inn which does not entitle the responsible party to a prorated refund.
Unfounded
Estimated Days of Completion: 0
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 26-AS-20211001124427
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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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This agency has investigated the complaint alleging facility failed to provide refund. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis
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
LIC9099 (FAS) - (06/04)
Page: 2 of 2