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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 275200867
Report Date: 03/20/2022
Date Signed: 03/20/2022 07:55:43 PM

Substantiated


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
09/07/2021 and conducted by Evaluator Jaclyn Avila
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20210907164214
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:
03/20/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Licensee Lita WilliamsTIME COMPLETED:
08:30 PM
ALLEGATION(S):
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Staff did not meet resident’s needs
Staff did not seek medical attention timely
Staff spoke inappropriately to resident
Insufficient staffing to meet the resident’s needs
INVESTIGATION FINDINGS:
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On 3/20/2022, 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 following are the findings:

This department reviewed medical records provided by Home Health, conducted interviews, reviewed documents, statements and communications between licensee, staff and responsible parties:

Cont'd on 9099-C
Substantiated
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: 03/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2022
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 7
Control Number 26-AS-20210907164214
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: 03/20/2022
NARRATIVE
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Home Health Registered Nurse (RN) notated on 5/27/2021, RN instructed patient (Resident/R1) and caregiver on use of assistive devices to ensure R1 is safe, R1 is always to use assistive device when up, R1 needs stand-by assistance to ambulate at all times. Home health instructed on environmental safety issues to resolve immediate hazards, keep clear pathways, eliminate clutter, keep telephone close, remove throw rugs. Records noted R1 has a diagnosis of dementia.

Home Health records notated by RN dated 6/4/2021: R1 said R1 feels as if R1 is burden to staff as R1 needs assistance to ambulate or use restroom. Per R1, R1 is told rude comments by staff and make R1 feel very uncomfortable belittled. Nurse noted there is a camera in the room to monitor R1 if abuse is happening per POA (Power of attorney).

In addition to R1 revealing to home health that staff made rude comments and belittled R1, R1 made similar statements and provided examples to others.

This department learned through interview and review of text exchanges scribed by Licensee Lita, on 6/8/2021, R1 landed on R1’s “tush.” Staff heard the bell and headed to R1’s room. Lita writes that when R1 doesn’t have tremors, R1 is able to get up and walk on R1’s own to the kitchen area. Lita goes on to state that, “There are times when R1 just want to be catered to and would insist that R1 would rather ride on R1’s walker.” On 6/11/21, Lita communicated that the night prior at 9PM, R1 was found on the floor and took another fall during the night. Lita communicated that night shift always puts on the monitor and was seen by staff walking.

Home Health records dated 6/21/21, notated by home health occupational therapist (OT), OT conducted a Fall risk assessment which revealed R1 is at risk for falling, depends entirely upon another person to dress and bathe. R1 needs assistance to toilet and transfer. R1 is able to walk only with supervision or assistance from another person at all times. R1 is a max assist with 24-hour care/supervision. Caregivers tell R1 to wait to use the bathroom so they can assist but due to resident frequently forgetting and attempts to ambulate on R1’s own.

OT noted on 7/13/21, R1 and caregiver reported a fall occurred over the weekend. R1 requires max verbal cues and tactile cues to complete task. R1 Requires caregiver assist for balance and frequent rest breaks. Caregiver educated regarding risks of decreased activity including increased falls.
Cont'd 9099-C
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 26-AS-20210907164214
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: 03/20/2022
NARRATIVE
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In a text dated 8/11/21, Lita states, “R1 been acting/feeling out of sorts last couple of days. I think it’s the Parkinson that’s making R1 act this way. R1 did end up being down on the floor once yesterday and again this evening. R1 gets out of bed forgetting to ring R1's bell and starts walking. on R1’s “falls" we don’t know how it happens. Yesterday we hear the noise and found R1 by the bed facing the lamp table. Tonight, R1 is in bed shortly after dinner, then, I was in the dining room doing medications for tomorrow…I heard a noise, run to R1’s room and R1 is on the floor in a sitting position leaning against the wall between the door and the cabinets where R1’s Christmas lights is the wheel chair is by R1’s feet.” In the text Lita states, R1 was not distressed and placed back in bed. Lita acknowledges R1 was not being supervised at time of fall.

Licensee/administrator did not seek immediate medical attention for this fall nor was the doctor or CCL notified by Lita although she reports R1 is “acting/feeling out of sorts.”

This department reviewed a picture of the area described by the licensee. The picture is of a hole in the wall where the fall is described to be. This department reviewed video of the room prior to the fall which did not reveal a hole in the wall. Lita acknowledges there was a “dent” in the wall that she had not noticed prior to the fall but does not know if that’s what caused it.

R1 was diagnosed with a urinary tract infection August 16th, 2021

An incident report submitted by Lita to CCL, notates that on 8/26/21, R1 suffered a medical emergency at which time 911 was called and R1 was hospitalized. On 8/30/21 per Lita, family would like R1 to return on hospice. Lita requested and was granted an increase from 2-3 residents on hospice with CCL provided she ensured substantial compliance.

R1 returned to the facility on 8/31/21 on hospice. Lita said she did not have a conversation with hospice as to the plan of care due to the short time frame. Lita did not obtain the Hospice care plan.

Cont'd 9099C
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 26-AS-20210907164214
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: 03/20/2022
NARRATIVE
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This department was provided with a picture of a urine saturated diaper that was taken at 12:30 AM on 9/3/21, with a message that R1 had not been changed since before 3 the day prior. This department obtained witness statements that when Lita was confronted about the lack of care, Lita admitted to being understaffed. The department learned that on 9/3/21, an additional family moved their loved one (R2) out of the facility who was also on hospice. On 9/3/21, two of the three residents on hospice were moved out of the facility by their responsible party due to lack of care and were told by Lita that she didn’t have the staffing and couldn’t find anyone to hire.

On 9/17/21, Lita provided the department with staff schedules for August and September of 2021. A review of the schedules provided revealed that there was not staffing scheduled between 6pm and 11PM during the time R1 had returned from hospice. Lita stated she lives at the facility and covers during this time. Lita stated her sister Becky who is also staff lives at the facility and will respond if needed.

Substantiated: Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D. 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: 03/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
09/07/2021 and conducted by Evaluator Jaclyn Avila
COMPLAINT CONTROL NUMBER: 26-AS-20210907164214

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:
03/20/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Licensee lita WilliamsTIME COMPLETED:
08:30 PM
ALLEGATION(S):
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Staff did not follow doctor's orders
INVESTIGATION FINDINGS:
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On 3/20/2022, 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 following are the findings:

Licensee did not obtain doctor's orders following Resident's (R1) discharge from the hospital on 8/31/21, nor did the Licensee obtain an agreed upon written hospice care plan, that specifies the care, services, and necessary medical intervention as required by the hospice waiver.
The above allegation is Unsubstantiated-Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 26-AS-20210907164214
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/21/2022
Section Cited
CCR
87625(b)(1)
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87625(b)(1)-Managed Incontinence-Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: Ensuring that residents who can benefit from scheduled toileting are assisted or reminded to go to the bathroom at regular intervals
This requirement is not met as evidenced by
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Licensee agrees to create an ADL sign off sheet for staff to include toileting. Plan will be submitted to LPA Avila on 3/21/21
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Based upon document review and interview: the Licensee failed to provide 1 of 1 residents with scheduled toileting or regular reminders. Instead staff would wait for a bell or to be called by R1 who had a diagnosis of dementia.

This poses an immediate Health, Safety and/or Personal Rights risk to Residents in care.
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Type A
03/21/2022
Section Cited
HSC
1569.3129(e)
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1569.3129(e) Basic services requirements
Every facility required to be licensed under this chapter shall provide at least the following basic services: Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being.
This requirement is not met as evidenced by:
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Licensee agrees to review regulations 87463 reappraisals and 87466 observation of resident and agrees to update the appraisal as often as needed. LIcensee agrees to keep a log of daily observations of residents in care. Licensee will submit a copy of the log to LPA Avila on 3/21/21
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Based upon document review and interview: the Licensee failed to provide 1 of 1 residents with supervision to ensure general health, safety and well being.

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: 03/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 26-AS-20210907164214
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/21/2022
Section Cited
CCR
87463(b)
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87463(b) Reappraisals-The licensee shall immediately bring any such changes to the attention of the resident's physician and family or responsible person.

This requirement is not met as evidenced by: Based upon document review and interview: the Licensee failed to immediatly notify
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LIcensee agrees to immediately notify resident's doctors regarding any changes to see how to proceed with care of resident. Licensee agrees to create a policy and train staff. POC due 3/21/21
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1 of 1 residents physician regarding R1's falls, increase in hallucinations, or R1 "acting/feeling out of sorts"

This poses an immediate Health, Safety and/or Personal Rights risk to Residents in care.
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Type A
03/21/2022
Section Cited
HSC
1569.269(a)(1)
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1569.269(a)(1) Enumerated rights; severability-Residents of residential care facilities for the elderly shall have all of the following rights: To be accorded dignity in their personal relationships with staff,

This requirement is not met as evidenced by:
Based upon observation, document review
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Licensee agrees to bring in an outside vendor to train staff on Resident rights. Licensee will provide confirmation of scheduled training on 3/21/21. At time of training Licensee will provide LPA Avila a copy of the sign off sheet of staff in attendance.
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 and interview: the Licensee failed to treat 1 of 1 residents with dignity. R1 had a diagnosis of dementia and needed supervision and instead the licensee tied a bell to R1 and told her to summon for assistance to be toileted.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: 03/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7