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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455000113
Report Date: 08/14/2023
Date Signed: 08/14/2023 09:42:35 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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
06/06/2023 and conducted by Evaluator Donna Gurriere
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20230606112225
FACILITY NAME:SHEPARD COURTFACILITY NUMBER:
455000113
ADMINISTRATOR:CARLEY, LANAFACILITY TYPE:
735
ADDRESS:1000 SHEPARD COURTTELEPHONE:
(530) 222-0765
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY:6CENSUS: 2DATE:
08/14/2023
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:LANA CARLEYTIME COMPLETED:
09:50 AM
ALLEGATION(S):
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Staff are administering residents vitamins without an authorized representative or physician's consent.
INVESTIGATION FINDINGS:
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On 08/14/23 Donna Gurriere and Jaynae Boyles, Licensing Program Analysts (LPAs) arrived at the facility unannounced to discuss the above mentioned allegation. LPAs met with Lana Carley, Administrator and explained the purpose of the visit.

During the visit, the medications were reviewed for two residents (Resident 1 and Resident 2). It was determined that some of the medications did not have a physician's prescription orders as required.

Resident 1 did not have the following orders, as required for Melatonin, Calcium Magnesum and Probiotics.
Resident 2 did not have the following orders, as required for Acidophilus, Calcium Magnesium and Niacin.

Based on investigation of a medication review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D.

Appeal Rights provided.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023
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 2
Control Number 59-AS-20230606112225
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SHEPARD COURT
FACILITY NUMBER: 455000113
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/15/2023
Section Cited
CCR
80075(b)(6)(D)
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Health Related Services - Clients shall be assisted as needed with self-administation of prescription and nonprescription medications.....There shall be a signed, dated written order from the physician.
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The administrator agrees to obtain the resident's prescription over-the-counter medications and shall submit proof of correction to the licensing agency.
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This requirement was not met as evidenced by: Based on a review of the residents medications.
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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.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2