397005614-10-27-2021-27-AS-ABOE-C884L2-20211027191113

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397005614
Report Date: 10/27/2021
Date Signed: 10/27/2021 07:12:34 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	SHEPHERD HOMES 1		FACILITY NUMBER:	397005614
ADMINISTRATOR:	JERMANE GUERZO		FACILITY TYPE:	740
ADDRESS:	5956 GLEN STREET		TELEPHONE:	(209) 478-2545
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95207
CAPACITY:	15	CENSUS: 15	DATE:	10/27/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	04:15 PM
MET WITH:	Ruth Banaga		TIME COMPLETED:	07:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 10/27/2021 Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a Required 1-year Annual Inspection at 4:15pm with Licensee Edgar Espiritu. Administrator Ruth Banaga arrived shortly after. LPA was allowed entry into the facility that is licensed to serve a total capacity of 15 and today's census is 15. Licensee accompanied LPA on facility tour. Five of five staff observed on site with criminal record clearance in Licensing Information System. LPA observed Administrator Certificate expires on 8/29/2022 and Licensee's Certificate expires on 3/20/2023. LPA interacted with a random number of residents during this visit and observed clients. The physical plant was toured inside and outside to ensure the safety of the clients. LPA observed kitchen, restrooms, bedrooms, and common living areas. LPA observed items not in use or good repair stored in backyard. LPA observed toxins, knives, centrally store medications stored inaccessible to residents. The temperature inside the facility was measured at 74F which is within the required range of 68F and 85F, or in areas of extreme heat the maximum shall be 30F less than the outside temperature. The hot water was measured at 107F within regulatory range of is not less than 105F and not more than 120*F. The first aid kit was found in compliance containing at least the following: a current edition of an approved first aid manual, but containing sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and antiseptic solution. LPA observed COVID precautions signs posted, restrooms stocked with paper towels, hand soap, touchless covered trash cans, and posted hand washing signs. 30 day supply of PPE stored on site. Stsff one (S1) stated common surfaces are disinfected daily and in between use. LPA observed hand sanitizer available throughout the facility. Observed MAR system in use but weekends in October not signed by facility staff, not documented when staff two (S2) was scheduled off. S2 stated medications are given but not signed off on MAR because other staff administer them but they do not write it down.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021

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 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SHEPHERD HOMES 1	FACILITY NUMBER: 397005614
	VISIT DATE: 10/27/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA observed fire extinguisher last inspected on 7/19/2021, fire suppression system last inspected on 3/2020. Observed smoke and carbon monoxide detectors, central heating and air in the facility. LPA observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times. The facility last conducted fire drill on 6/20/2021.

Upon a file review the following items were discussed to be submitted with any changes annually:
Designation of Administrative Responsibility LIC308
Personnel Report LIC500
Administrator Certificate
Emergency Disaster Plan LIC610E
Liability Insurance
Health Screening Report-Facility Personnel LIC503
First Aid/ CPR certificates

Per California Code of Regulations (CCRs) - Title 22, Division 6, the following deficiencies are being cited on the attached 809D during this visit. Civil penalties shall be assessed when the licensee fails to correct the violation and any appropriate extensions to the plan of correction due date. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview held and a copy of report was given.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021

LIC809 (FAS) - (06/04)

Page: 2 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SHEPHERD HOMES 1	FACILITY NUMBER: 397005614
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/27/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(a)(1)

Incidental Medical and Dental Care Services

(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in that observed MAR system in use but weekends in October not signed by facility staff, not documented when staff two (S2) was scheduled off. S2 stated medications are given but not signed off on MAR because other staff administer them but they do not write it down which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/29/2021
	Plan of Correction
1 2 3 4	The licensee agrees to submit planned date of medication audit and staff in service scheduled to LPA by POC due date. Proof of completion due upon scheduled date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021

LIC809 (FAS) - (06/04)

Page: 3 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SHEPHERD HOMES 1	FACILITY NUMBER: 397005614
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/27/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87203

Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and records review, the licensee did not comply with the section cited above that fire suppression system was last inspected in 3/2020 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/29/2021
	Plan of Correction
1 2 3 4	The licensee agrees to submit planned date of inspection scheduled to LPA by POC due date. Proof of completion due upon scheduled date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021

LIC809 (FAS) - (06/04)

Page: 6 of 6