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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397005616
Report Date: 07/29/2026
Date Signed: 07/29/2026 11:20:56 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/06/2026 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20260506142813
FACILITY NAME:SHEPHERD HOMES 2FACILITY NUMBER:
397005616
ADMINISTRATOR:ADELFA RUTH BANAGAFACILITY TYPE:
740
ADDRESS:5964 GLEN STREETTELEPHONE:
(209) 478-2170
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:15CENSUS: 14DATE:
07/29/2026
UNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Edgar EspirituTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Resident sustained 2nd and 3rd degree burns due to lack of supervision
Staff did not obtain medical care for resident
Staff do not ensure resident's showering needs are met
INVESTIGATION FINDINGS:
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On 7-29-2026 at 9:52am, Licensing Program Analyst (LPA) Michael Bilger arrived at the facility unannounced to deliver and discuss findings for the allegations noted above. LPA met with Administrator Edgar Espiritu and explained the purpose of the visit. During this investigation, LPA conducted interviews with four staff members, two residents in care and one additional witness. Additionally, LPA reviewed facility file documentation including incident reports, medication log sheets, physician’s report, progress notes, and bath/shower schedule. LPA also reviewed additional medical records as part of this investigation.

Allegation: Resident sustained 2nd and 3rd degree burns due to lack of supervision. LPA conducted interviews and record reviews as noted above. Based on interviews and record reviews it was determined that on 4-29-2026 at approximately 11:00am the facility cook handed a hot cup of noodle soup to resident1 (R1) and left the room. Interviews conducted further revealed that an overbed table was not utilized for support and safety.
{Cont. on 9099C}
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026
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 7
Control Number 27-AS-20260506142813
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SHEPHERD HOMES 2
FACILITY NUMBER: 397005616
VISIT DATE: 07/29/2026
NARRATIVE
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The following deficiencies were observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22, Division 6, and Health and Safety Codes. Failure to correct the deficiencies may result in additional civil penalties. An immediate civil penalty in the amount of five-hundred dollars ($500) was issued in addition to citation due to a violation resulting in a severe injury. At the time of the complaint visit, the issuance of an additional Civil Penalty was still being determined, and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(f). An exit interview was conducted with Administrator , and a copy of this report was provided. Appeal rights provided. LIC 811 provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 27-AS-20260506142813
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SHEPHERD HOMES 2
FACILITY NUMBER: 397005616
VISIT DATE: 07/29/2026
NARRATIVE
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Additionally, it was revealed that a caregiver was not present to assist and ensure safety given resident was not utilizing an overbed table. After the soup was handed to R1, R1 spelt the soup on her upper left thigh area at approximately 11:35am which initially caused redness. It was later revealed on 5-1-2026 that R1 sustained a 2nd degree burn. As a result, there is a preponderance of evidence to conclude that staff did not utilize an appropriate supervision procedure given the knowledge that R1 was not using an overbed table or other device to support R1’s self feeding of a hot liquid food item, resulting in risk and eventual injury to R1, therefore, this allegation is SUBSTANTIATED.

Allegation: Staff did not obtain medical care for a resident. LPA conducted interviews and record reviews as noted above. Based on interviews and record reviews it was determined that on 4-29-2026 at approximately 11:00am the facility cook handed a hot cup of noodle soup to resident1 (R1) and walked away. After the soup was handed to R1, R1 spelt the soup on her upper left thigh area at approximately 11:35am which initially caused redness. It was further revealed that after learning of the incident, staff did not initially call 911 for immediate evaluation and determination for treatment. At approximately 3-3:30pm on 4-29-2026, an outside medical professional observed the redness and gave a verbal direction to apply ointment. It was later revealed on 5-1-2026 that R1 sustained a 2nd degree burn. Additional interviews revealed that given this incident, 911 was not called and should have been called. As a result, there is a preponderance of evidence to conclude that staff did not utilize the regulatory requirement of calling 911 as noted in Section 87465(g) when the injury and imminent threat to health occurred, therefore, this allegation is SUBSTANTIATED.

Allegation: Staff do not ensure resident’s showering needs are met. LPA conducted interviews and record reviews as noted above. Based on interviews and record reviews it was determined that R1 was admitted to facility in March 2026. Shower records revealed that R1 was offered showers on 3-20-2026, 3-28-2026, 4-5-2026, and 4-10-2026 with refusals by R1 noted. Records did not reveal additional shower offerings beyond 4-10-2026 and up to R1’s discharge on or about 4-30-2026. Furthermore, records did not reveal additional shower offerings after R1 refused. A review of R1’s physician’s report revealed that R1 was unable to bathe self and required assistance. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.

{Cont. on 9099C}

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/06/2026 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20260506142813

FACILITY NAME:SHEPHERD HOMES 2FACILITY NUMBER:
397005616
ADMINISTRATOR:ADELFA RUTH BANAGAFACILITY TYPE:
740
ADDRESS:5964 GLEN STREETTELEPHONE:
(209) 478-2170
CITY:STOCKTONSTATE:CAZIP CODE:
95207
CAPACITY:15CENSUS: 14DATE:
07/29/2026
UNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Edgar EspirituTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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2
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Staff do not provide activities for residents
INVESTIGATION FINDINGS:
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On 7-29-2026 at 9:52am Licensing Program Analyst (LPA) Michael Bilger arrived at the unannounced facility to deliver and discuss findings for the allegation noted above. LPA met with Administrator Edgar Espiritu and explained the purpose of the visit. During this investigation, LPA conducted interviews with four staff members, and two residents in care. Additionally, LPA conducted facility observation.

Allegation: Staff do not provide activities for residents. LPA conducted interviews and observation as noted above. Based on interviews conducted, it was revealed that facility has utilized and offered various activities to residents in care. LPA observed a posted activity calendar describing various activities offered. Additionally, LPA observed activities taking place during a visit on 7-15-2026. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator and a copy of this report was provided. Appeal rights provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/06/2026 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20260506142813

FACILITY NAME:SHEPHERD HOMES 2FACILITY NUMBER:
397005616
ADMINISTRATOR:ADELFA RUTH BANAGAFACILITY TYPE:
740
ADDRESS:5964 GLEN STREETTELEPHONE:
(209) 478-2170
CITY:STOCKTONSTATE:CAZIP CODE:
95207
CAPACITY:15CENSUS: 14DATE:
07/29/2026
UNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Edgar EspirituTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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2
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Staff do not follow reporting requirements
INVESTIGATION FINDINGS:
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On 7-29-2026 at 9:52am Licensing Program Analyst (LPA) Michael Bilger arrived at the unannounced facility to deliver and discuss findings for the allegation noted above. LPA met with Administrator Edgar Espiritu and explained the purpose of the visit. During this investigation, LPA conducted interviews with four staff members, and one additional witness. Additionally, LPA reviewed facility file documentation including incident reports related to an event which occurred on 4-29-2026, and facility progress notes.

Allegation: Staff do not follow reporting requirements. Based on interviews and record reviews, resident1 (R1) experienced an episode which resulted in an injury on 4-29-2026. On 5-4-2026, the Department received a copy of the incident report. Additional documentation review revealed that responsible person for R1 was made aware of the incident verbally and in written format on 5-4-2026. As result, the preponderance of evidence standard is not met, and this allegation is UNFOUNDED. A finding of unfounded means the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted with Administrator and a copy of this report was provided.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 27-AS-20260506142813
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SHEPHERD HOMES 2
FACILITY NUMBER: 397005616
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/07/2026
Section Cited
HSC
1569.312(a)
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1569.312 Basic Service Requirements. (a) Care and supervision as defined in Section 1569.2. This requirement was not met as evidence by:
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Licensee to develop and submit a plan outlining how staff will consistently meet and/or attempt to meet residents’ showering needs and other assistance with activities of daily living needs. Plan to be submitted to LPA by POC due date.
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Based on record reviews and interviews, Licensee did not ensure additional offerings of showers and shower assistance to R1 in relation to length of R1’s residency at facility. This posed a potential health, safety, and resident rights risk to residents in care.
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Licensee will read Section 1569.2 and submit a written declaration of understanding of the definition of “care and supervision” to LPA by POC due date.
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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 King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 27-AS-20260506142813
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SHEPHERD HOMES 2
FACILITY NUMBER: 397005616
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/30/2026
Section Cited
HSC
1569.312(e)
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1569.312 Basic Service Requirements. (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. This requirement was not met as evidenced by:
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Licensee to ensure completed staff training on proper supervision of residents in care. Training date to be submitted to LPA by POC due date. Proof of completed training to be sent to LPA no later than 8/14/2026.
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Based on interviews and record reviews, Licensee did not ensure adequate level of supervision for R1 resulting in a severe injury to R1. This posed an immediate health and safety risk to resident in care.
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Licensee to develop and submit a protocol outlining proper supervision procedures of residents. Protocol to include various examples of scenarios which constitute certain levels of supervision. Protocol to be submitted to LPA by POC due date.
Type A
07/30/2026
Section Cited
CCR
87465(g)
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87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health…This requirement was not met as evidenced by:
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Licensee will ensure completed staff training on Section 87465(g). Training to include proper response to emergencies and when to call 911. Training date to be submitted to LPA by POC due date. Proof of completed training to be submitted to LPA no later than 8/14/2026.

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Based on interviews and record reviews, Licensee did not ensure the immediate call to 911 after learning of hot soup spilling onto R1’s thigh area. This posed an immediate health and safety risk to resident in care.
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Licensee to develop and submit a protocol outlining procedures of when to call 911. Protocol to include various examples of scenarios which constitute a call to 911 Protocol to be sent to LPA by POC due 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: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 7