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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397005614
Report Date: 12/07/2022
Date Signed: 12/07/2022 11:39:21 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/30/2022 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20221130130943
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:
12/07/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Edgar EspirituTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff did not supervise resident adequately resulting in resident wandering from the facility.
INVESTIGATION FINDINGS:
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On 12/7/22 at XXXX Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegation.

On 12/2/22 LPA Jensen interviewed staff 1 (S1) and staff 2 (S2). S1 confirmed that on the date in question, at approximately 4pm, staff reported resident 1 (R1) missing from the facility. Law enforcement and the responsible party for R1 were notified. Social media posts were also made seeking assistance in finding R1. LPA Jensen was advised by both staff members that resident 1 often left the facility grounds but never went far from the facility and always came back. S2 also confirmed during the course of the interview that on the date in question, resident 1 went outside the facility in to the front yard unsupervised at approximately 3:30pm.

Continued on LIC 9099C....
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20221130130943
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/07/2022
NARRATIVE
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LPA Jensen also reviewed R1's file and determined that an LIC 624 that was completed for R1 on 2/22/22.The LIC 624 states that R1 cannot leave the facility unsupervised.

LPA Jensen reviewed the Admission Agreement for R1. The Admission Agreement states under section 2A that the facility agrees to provide "continuous observation, care and supervision".

Based on interviews conducted and records reviewed the allegation of staff did not supervise resident adequately resulting in resident wandering from the facility is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met.

Deficiencies are being cited from the California Code of Regulations (CCR), Title 22, Division 6. Failure to correct deficiencies may result in civil penalties.

An exit interview was conducted and a copy of this report and appeal rights were given to the Licensee.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 27-AS-20221130130943
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/14/2022
Section Cited
CCR
87468.2(a)(4)
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(a) ...residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
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(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.

This requirement was not met as evidenced by:
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The licensee agrees to cease accepting residents with a diagnosis of dementia and will submit an addendum to the plan of operation for review by Community Care Licensing should they choose to provide dementia care in the future. The Licensee will email confirmation of this plan to LPA Jensen at maja.jensen@dss.ca.gov by the plan of correction due date.
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Based on interviews conducted and records reviewed the licensee did not adequately supervise R1 resulting in R1 wandering from the facility. This poses a potential health, safety and personal rights risk to residents in care.
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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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3