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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455000113
Report Date: 10/04/2023
Date Signed: 10/04/2023 11:48:32 AM

Document Has Been Signed on 10/04/2023 11:48 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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:
10/04/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Lana CarleyTIME COMPLETED:
12:15 PM
NARRATIVE
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On 10/03/2023 Licensing Program Analysts (LPA) Ivan Avila and Jaynae Boyels arrived at the facility for a case management visit and met with Lana Carley and explained the purpose of the visit.

During todays inspection, Licensee denied LPAs access to Staff room. Licensee stayed the Staff room is her over night room. Licensee also stated LPAs can return to inspect the room when it is cleaned. LPA informed Licensee that LPAs have inspection authority and is able to inspect all parts of the facility. Licensee informed LPAs she would like to adjust her facility sketch to eliminate the Staff room from the LIC 999 form.

During todays inspection a deficiency was observed, please refer to 809D and a copy of the report and appeal rights were provided to Lana Carley.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Ivan Avila
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2023
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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Document Has Been Signed on 10/04/2023 11:48 AM - It Cannot Be Edited


Created By: Ivan Avila On 10/04/2023 at 11:00 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SHEPARD COURT
FACILITY NUMBER: 455000113

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/05/2023
Section Cited
HSC
1533(a)

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1533(a) Except as otherwise provided in this section, any duly authorized officer... enter and inspect any place providing personal care... with or without advance notice, to secure compliance with, or to prevent a violation of, any provision of this chapter. The requirement is not met as evidence by:
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An office meeting will be held to discuss this matter. LPA Avila will update Licensee with time and date. Licensee's attendance is mandatory.

Immediate $500 penalty assesed
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Based on observation, the licensee did not comply with the section cited above as Licensee denied LPAs entry to a staff room based on the facility sketch, which poses an immediate Health, Saftety, and Personal Rights risk to persons 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:Lauren Crocker
LICENSING EVALUATOR NAME:Ivan Avila
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023


LIC809 (FAS) - (06/04)
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