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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005616
Report Date: 03/27/2023
Date Signed: 03/27/2023 11:49:25 AM

Document Has Been Signed on 03/27/2023 11:49 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 2FACILITY NUMBER:
397005616
ADMINISTRATOR:ADELFA RUTH BANAGAFACILITY TYPE:
740
ADDRESS:5964 GLEN STREETTELEPHONE:
(209) 478-2170
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 15CENSUS: 15DATE:
03/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Edgar EsprituTIME COMPLETED:
12:00 PM
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On 3/27/23 Licensing Program Analysts (LPAs) Maja Jensen and Jennifer Fain arrived at facility unannounced to conduct a case management for Resident 1 (R1) based on an LIC 624A that was received. LPAs met with licensee Edgar Espiritu and explained the purpose of today's visit.

LPA Jensen interviewed the Licensee and staff 1 (S1). LPA Jensen also reviewed the file for R1 and determined that the Needs and Service Plan, Medication Administration Record, Physician Report, Weight Record were all complete, current and in compliance. Based on LPA Jensen's record review, R1 appears to have passed from natural causes. No citations are being issued as a result of this visit.

An exit interview was conducted and a copy of this report and appeal rights were given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2023
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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