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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005616
Report Date: 10/27/2021
Date Signed: 10/27/2021 07:14:56 PM

Document Has Been Signed on 10/27/2021 07:14 PM - 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:JERMANE GUERZOFACILITY TYPE:
740
ADDRESS:5964 GLEN STREETTELEPHONE:
(209) 478-2170
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 15CENSUS: 13DATE:
10/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Ruth BangaTIME COMPLETED:
07:15 PM
NARRATIVE
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On 10/27/2021 Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a Required 1-year Annual Inspection at 4:15pm with Licensee Edgar Espiritu. Administrator Ruth Banga arrived shortly after. LPA was allowed entry into the facility that is licensed to serve a total capacity of 15 and today's census is 13. Licensee accompanied LPA on facility tour. Four of four staff observed on site with criminal record clearance in Licensing Information System. One of one staff observed cleared but not associated, observed transfer request submitted, LPA to process association. LPA observed Administrator Certificate expires on 8/29/2022 and Licensee's Certificate expires on 3/20/2023.

LPA interacted with a random number of residents during this visit and observed clients. The physical plant was toured inside and outside to ensure the safety of the clients. LPA observed kitchen, restrooms, bedrooms, and common living areas. LPA observed paint and items not in use or good repair stored in backyard. LPA observed toxins, knives, centrally store medications stored inaccessible to residents. The temperature inside the facility was measured at 75*F which is within the required range of 68*F and 85*F, or in areas of extreme heat the maximum shall be 30*F less than the outside temperature. The hot water was measured at 112*F within regulatory range of is not less than 105*F and not more than 120*F. Kitchen hot water measured at 127*F not accessible to residents. The first aid kit was found in compliance containing at least the following: a current edition of an approved first aid manual, but containing sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and antiseptic solution. LPA observed COVID precautions signs posted, restrooms stocked with paper towels, hand soap, touchless covered trash cans, and posted hand washing signs. 30 day supply of PPE stored on site. Staff one (S1) stated common surfaces are disinfected daily and in between use. LPA observed hand sanitizer available throughout the facility. Observed medications not administered per physician's orders in that Resident one (R1) PRN narcotic administration 3 times daily did not match medications count, 2 pills missing from start date beginning quantity of 42 and PRN log not documented administrations.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 2
FACILITY NUMBER: 397005616
VISIT DATE: 10/27/2021
NARRATIVE
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LPA observed fire extinguisher last inspected on 7/19/2021, fire suppression system last inspected on 2/4/2020, last sticker placed in 11/2019 on fire suppression system. Observed smoke and carbon monoxide detectors, central heating and air in the facility. LPA observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times. LPA observed food sitting on the floor in kitchen and food debris in refrigerator not clean. The facility last conducted fire drill on 6/20/2021.

Upon a file review the following items were discussed to be submitted with any changes annually:
Designation of Administrative Responsibility LIC308
Personnel Report LIC500
Administrator Certificate
Emergency Disaster Plan LIC610E
Liability Insurance
Health Screening Report-Facility Personnel LIC503
First Aid/ CPR certificates

Per California Code of Regulations (CCRs) - Title 22, Division 6, the following deficiencies are being cited on the attached 809D during this visit. Civil penalties shall be assessed when the licensee fails to correct the violation and any appropriate extensions to the plan of correction due date. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview held and a copy of report was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 10/27/2021 07:14 PM - It Cannot Be Edited


Created By: Ashley Boothe On 10/27/2021 at 05:57 PM
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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SHEPHERD HOMES 2
FACILITY NUMBER: 397005616

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in that LPA observed food sitting on the floor in kitchen and food debris in refrigerator not clean. LPA observed paint and items not in use or good repair stored in backyard which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/24/2021
Plan of Correction
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The licensee agrees to provide proof of items removed, repaired, or cleaned to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Ashley Boothe
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2021


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 10/27/2021 07:14 PM - It Cannot Be Edited


Created By: Ashley Boothe On 10/27/2021 at 06:21 PM
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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SHEPHERD HOMES 2
FACILITY NUMBER: 397005616

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and records review, the licensee did not comply with the section cited above that fire suppression system last inspected on 2/4/2020, last sticker placed in 11/2019 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2021
Plan of Correction
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The licensee agrees to submit planned date of inspection scheduled to LPA by POC due date. Proof of completion due upon scheduled date.
Type A
Section Cited
CCR
87465(c)(2)
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and records review, the licensee did not comply with the section cited above that medications not administered per physician's orders in that Resident one (R1) PRN for administration 3 times daily did not match medications count, 2 pills missing from start date beginning quantity of 42 and PRN log not documented administrations which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2021
Plan of Correction
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The licensee agrees to submit planned date of medication audit and schedule an in service scheduled to LPA by POC due date. Proof of completion due upon scheduled 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:Ashley Boothe
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2021


LIC809 (FAS) - (06/04)
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