275200867-8-15-2023-24-AS-BMIA-CUR4C4-20230815185830

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 275200867
Report Date: 08/15/2023
Date Signed: 08/15/2023 06:58:45 PM

Document Has Been Signed on 08/15/2023 06:58 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	SHEPHERD'S INN		FACILITY NUMBER:	275200867
ADMINISTRATOR:	WILLIAMS, LITA P.		FACILITY TYPE:	740
ADDRESS:	11899 CYPRESS CIRCLE		TELEPHONE:	(831) 632-2200
CITY:	CASTROVILLE	STATE: CA	ZIP CODE:	95012
CAPACITY:	6	CENSUS: 6	DATE:	08/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:31 PM
MET WITH:	Staff- RJ (Marino) Pascual		TIME COMPLETED:	06:45 PM

NARRATIVE

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On 8/15/2023 at 12:31 p.m. Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to conduct an annual inspection. LPA was greeted by staff. Administrator Lita Williams was contacted but will not be able to come to the facility. RJ (Marino) Pascual was contacted and arrived at the facility later.

LPA toured the facility inside and out. Facility currently has 6 residents. Each resident has their own bedroom with a door leading to outside for emergency purposes, doors have alarms. LPA observed residents interacting with staff, watching TV, and in their bedrooms.

LPA observed facility to have sufficient perishable and non-perishable food items. LPA observed some canned food items to be expired. LPA observed food at facility to not be labeled properly. LPA was not able to distinguish between residents’ food and live in staff food. LPA observed one drawer in the kitchen had scissor which were not locked. Garage/storage door was not locked, this gave residents access to knives. LPA observed cleaning supplies under the kitchen sink to not be locked.

Sample of staff files were reviewed, and current training is missing for staff.

Resident’s files were reviewed, emergency contact information needs to be completed and up to date with current doctor and dentist contact information. LPA observed centrally stored medication log to not be complete.

Facility needs a Plan of Operation, Plan of Operation for Dementia, Disaster Plan, Infection Control Plan to be readily available at the facility.

Exit interview was conducted. A copy of LIC809, 809D, and appeal rights were provided to staff RJ (Marino) Pascual

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna Miranda	TELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

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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Document Has Been Signed on 08/15/2023 06:58 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SHEPHERD'S INN	FACILITY NUMBER: 275200867
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(8)

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation & interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed expired foods and food not labeled properly.
	POC Due Date: 08/16/2023
	Plan of Correction
1 2 3 4	Staff will send a procedure to be put in place to prevent expired food being stored in the facility.

Type A

Section Cited

CCR

87465(a)(6)

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed Centrally Stored Medication Log to not be completed properly. Log did not have a start date.
	POC Due Date: 08/16/2023
	Plan of Correction
1 2 3 4	Staff will be trained to complete log in it's entirety.

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: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna Miranda	TELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/15/2023 06:58 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SHEPHERD'S INN	FACILITY NUMBER: 275200867
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation & interview, the licensee did not comply with the section cited which poses an immediate health, safety or personal rights risk to persons in care. LPA observed garage door to be unlocked which had knives accessible to residents. One drawer in the kitchen was unlocked which had scissors accessible to residents.
	POC Due Date: 08/16/2023
	Plan of Correction
1 2 3 4	Scissors will be removed from kitchen drawer and notice will be given to staff to inform garage door will remain locked at all times. Copy of notice will be provided to LPA.

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation & interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed bleach and other cleaning products under an unlocked kitchen sink.
	POC Due Date: 08/16/2023
	Plan of Correction
1 2 3 4	Cleaning supplies will be removed from under the sink. Picture will be sent to LPA.

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: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna Miranda	TELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/15/2023 06:58 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SHEPHERD'S INN	FACILITY NUMBER: 275200867
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(9)

General Food Service Requirements

(b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Garage area used to cook certain foods needs to be free from clutter, cleaned, and maintained. Dirty dishes and food not properly stored is left out which can attract rodents.
	POC Due Date: 08/25/2023
	Plan of Correction
1 2 3 4	Clean and organize. Pictures will be sent to LPA.

Type B

Section Cited

CCR

87555(b)(27)

General Food Service Requirements

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed garage area used to store food needs to be clutter free in order to prevent pests. Outside refrigerator used to store resident's food needs to be cleaned.
	POC Due Date: 08/25/2023
	Plan of Correction
1 2 3 4	Clean and organize. Pictures will be sent to LPA.

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: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna Miranda	TELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 08/15/2023 06:58 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SHEPHERD'S INN	FACILITY NUMBER: 275200867
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(28)

General Food Service Requirements

(b) The following food service requirements shall apply: (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation & interview, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed an open package of bacon to be stored with a open package of sliced cheese (raw meat with dairy). Neither item was stored properly causing contamination.
	POC Due Date: 08/25/2023
	Plan of Correction
1 2 3 4	Staff will properly store opened items. Pictures will be sent to LPA.

Type B

Section Cited

HSC

1569.695(a)

Other Provisions

(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above ] which poses/posed a potential health, safety or personal rights risk to persons in care. Facility was not able to provide an emergency/disaster plan for the facility.
	POC Due Date: 08/25/2023
	Plan of Correction
1 2 3 4	Facility will submit plan to LPA.

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: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna Miranda	TELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

LIC809 (FAS) - (06/04)

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