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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005614
Report Date: 07/08/2022
Date Signed: 07/08/2022 02:33:56 PM


Document Has Been Signed on 07/08/2022 02:33 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:SHEPHERD HOMES 1FACILITY NUMBER:
397005614
ADMINISTRATOR:ADELFA RUTH BANAGAFACILITY TYPE:
740
ADDRESS:5956 GLEN STREETTELEPHONE:
(209) 478-2545
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:15CENSUS: 15DATE:
07/08/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Helen ArtesTIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management visit for health and safety checks. LPA met with caregiver Helen Artes and explained the purpose of today's visit.

LPA Jensen toured the facility including common areas, resident bedrooms, grounds and kitchen. The facility had the thermostat set at 76 degrees which falls within the required regulatory range. The facility was observed to have in excess of 2 days of perishable food and 7 days of non-perishable food. LPA Jensen interacted with 15 of 15 residents. All residents indicated they were well and are treated well.

LPA Jensen returned 3 resident files that were retrieved during the course of a site visit on 6/28/22.

No deficiencies from the California Code of Regulations, Title 22 or the Health and Safety code were cited as a result of today's visit. An exit interview was conducted and a copy of this report was handed to care provider Helen Artes.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2022
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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