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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
275200867
Report Date:
07/27/2024
Date Signed:
07/27/2024 03:52:54 PM
Document Has Been Signed on
07/27/2024 03:52 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:
07/27/2024
TYPE OF VISIT:
Case Management - Annual Continuation
UNANNOUNCED
TIME BEGAN:
01:00 PM
MET WITH:
Licensee Lita Williams
TIME COMPLETED:
04:15 PM
NARRATIVE
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On 7/27/24 Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to complete the annual inspection. LPA met with Licensee Lita Williams.
On 7/9/24 LPA observed the following deficiencies:
Smoke detectors were not present in the home, Administrator was not able to provide verification the sprinkler system is in working condition.
Gardening tools were in an unlocked drawer in kitchen which are accessible to residents in care.
Toxins and cleaning supplies were stored in a cabinet under the sink and in a cabinet next to the sink which was unlocked. The garage also has cleaning supplies which was not locked.
Canned food and additional refrigerators are stored in the garage area which is not clean and has rodent droppings throughout the garage.
Garage is used to store food which is not being maintained.
Garage area used for additional kitchen is not being maintained.
Food is not being stored or labeled properly.
Medications are not being logged on the centrally stored medication log.
There are no audio alarms on the exits and dementia residents reside in the facility.
Staff use R1's room to go outside to throw the trash.
Staff member S1 was at the facility without being properly associated to the facility. LPA observed staff at the facility.
Staff member S2 was on the staff schedule and was working NOC shift according to Licensee.
Licensee will provide insurance verification by 8/6/24. Citations were issued per Title 22.
Exit interview was conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to Administrator Lita Williams.
SUPERVISOR'S NAME:
Brenda Chan
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR NAME:
Brianna Miranda
TELEPHONE:
559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE:
07/27/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/27/2024
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
7
Document Has Been Signed on
07/27/2024 03:52 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:
07/27/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:
This requirement is not met as evidenced by:
Deficient Practice Statement
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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. During the annual inspection on 7/9/24 Licensee stated the sprinkler alarm had not been serviced for a few years and the smoke detectors were removed because they are too loud.
POC Due Date:
07/30/2024
Plan of Correction
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Licensee stated they would add smoke alarms to the facility and as of 7/27/24 there were new smoke alarms added to the facility.
Type A
Section Cited
CCR
87307(d)(2)
Personal Accommodations and Services
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.
This requirement is not met as evidenced by:
Deficient Practice Statement
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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 garage to not be maintained and is accessible to residents.
POC Due Date:
07/30/2024
Plan of Correction
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Licensee will provide a plan/procedure to clean garage. Verificaiton garage has been cleaned will be provided by 8/6/24 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:
07/27/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/27/2024
LIC809
(FAS) - (06/04)
Page:
2
of
7
Document Has Been Signed on
07/27/2024 03:52 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:
07/27/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) 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:
Deficient Practice Statement
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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. During the visit on 7/9/24 LPA observed cleaning supplies & toxins to be unlocked and accessible under the kitchen sink and a cabinet on the side of the sink.
POC Due Date:
07/30/2024
Plan of Correction
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on 7/27/24 LPA observed cleaning supplies to be removed from under the sink. The cabinet on the side of the sink will be locked and verification will be sent to LPA.
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
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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 non-perishable food items to not be kept in clean area away from rodent droppings. LPA observed food items in refrigerators to not be properly labeled.
POC Due Date:
07/30/2024
Plan of Correction
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Licensee will put a plan/procedure will be put into place and verification 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:
07/27/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/27/2024
LIC809
(FAS) - (06/04)
Page:
3
of
7
Document Has Been Signed on
07/27/2024 03:52 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:
07/27/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(22)
General Food Service Requirements
(b) The following food service requirements shall apply: (22) Adequate space shall be maintained to accommodate equipment, personnel and procedures necessary for proper cleaning and sanitizing of dishes and other utensils.
This requirement is not met as evidenced by:
Deficient Practice Statement
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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 additional kitchen area to be kept in the garage which is used for cooking fish according to the Licensee. LPA observed kitchen to be kept unclean which does not prevent rodents and insect causing items in the garage to not be clean or sanitized.
POC Due Date:
07/30/2024
Plan of Correction
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Licensee will put a plan/procedure will be put into place on how to maintain kitchen in the garage, and verification will be sent to LPA.
Type A
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
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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 a container with rice to be been chewed through by a rodents leaving the rice to be contaminated. Disposable cups were also contaminated due to being chewed by rodents.
POC Due Date:
07/30/2024
Plan of Correction
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Licensee will put a plan/procedure will be put into place and verification 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:
07/27/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/27/2024
LIC809
(FAS) - (06/04)
Page:
4
of
7
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:
07/27/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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
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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 kitchen in garage to be contaminated with droppings from rodents, dirty dishes and trash were in garage.
POC Due Date:
07/30/2024
Plan of Correction
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Licensee will put a plan/procedure will be put into place how to prevent rodent and insects from kitchen in the garage, and verification will be sent to LPA.
Type A
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
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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. Due to food being kept in the garage it is considered contaminated and needs to be maintained.
POC Due Date:
07/30/2024
Plan of Correction
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3
4
Licensee will put a plan/procedure will be put into place to prevent food items from being contaminated, and verification 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:
07/27/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/27/2024
LIC809
(FAS) - (06/04)
Page:
of
Document Has Been Signed on
07/27/2024 03:52 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:
07/27/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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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 a sample of resident files which did not have completed centrally stored medication logs.
POC Due Date:
07/30/2024
Plan of Correction
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2
3
4
Licensee will put a plan/procedure will be put into place to maintain resident's medication log and verification will be sent to LPA.
Type A
Section Cited
CCR
97355(e)(1)(2)
87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department or
(2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or
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.
POC Due Date:
07/30/2024
Plan of Correction
1
2
3
4
Staff are not to return to the facility until proper clearance and association to the facility has been completed. Licensee will provide verification 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:
07/27/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/27/2024
LIC809
(FAS) - (06/04)
Page:
6
of
7
Document Has Been Signed on
07/27/2024 03:52 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:
07/27/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(2)(B)
Personal Accommodations and Services
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building.
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 staff using R1's room as common use to take trash to the outside bins.
POC Due Date:
08/06/2024
Plan of Correction
1
2
3
4
Licensee will put a plan/in place which will prevent the staff from using R1's room to exit facility to throw away trash, and verification will be sent to LPA.
Type B
Section Cited
CCR
87506(b)(13)
Resident Records
(b) Each resident's record shall contain at least the following information: (13) Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or the services he needs.
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. LPA did not observe proper documentation in resident's files regarding a change in status.
POC Due Date:
08/06/2024
Plan of Correction
1
2
3
4
Licensee will maintain all resident files and the plan to maintain files 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:
07/27/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/27/2024
LIC809
(FAS) - (06/04)
Page:
7
of
7