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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005614
Report Date: 09/24/2022
Date Signed: 09/26/2022 08:17:29 AM


Document Has Been Signed on 09/26/2022 08:17 AM - 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:
09/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator, Edgar EspirituTIME COMPLETED:
02:00 PM
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Licensing Program Analysts (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Edgar Espiritu Continual Administrator's Certification expires 03/20/2023. There are currently 15 residents who reside at this home and there is 1 residents on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.
Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 110 degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible.

The Licensee does not have staff COVID 19 vaccine cards or exemptions on file for all facility staff.

LPA observed the outside of the facility to have old bikes, children's toys, and trash around the sides of the facility, and backyard area.

LPA observed the facility refrigerator to have several containers with food inside not labeled or dated.

The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA's requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Administrator, Edgar Espiritu and copy of report left at facility
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2022
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 2


Document Has Been Signed on 09/26/2022 08:17 AM - 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
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: 09/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in LPA observed trash, unused bikes, vehicles, and children’s toys around the sides and backyard area of the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2022
Plan of Correction
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Administrator will clean the backyard area and sides of the facility and send proof to LPA by 10/07/2022 POC date.
Type B
Section Cited
CCR
87555(9)
General Food Requirements:(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 LPA observation the facility refrigerator has several containers without dates or labels which poses a potential health, safety risk to residents in care.
POC Due Date: 10/07/2022
Plan of Correction
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Administrator will clean the facility fridge and send proof to LPA by 10/07/2022 POC date.

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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2022
LIC809 (FAS) - (06/04)
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