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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397005616
Report Date: 09/14/2022
Date Signed: 09/14/2022 01:15:24 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/26/2022 and conducted by Evaluator Maja Jensen
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220826123615
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: DATE:
09/14/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Edgar EspirituTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility staff does not keep the home free from insects
INVESTIGATION FINDINGS:
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On 9/14/22 at approximately 10am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegations. LPA Jensen met with Administrator Edgar Espiritu and explained the purpose of today's visit.

Upon arrival LPA Jensen observed that the facility front door was fully open and there is no screen in place. LPA Jensen also observed 2 spiders in the top right corner of the entrance hall next to the open door. LPA Jensen observed a spider and webbing along the light fixture over the sink in the resident bathroom located closest to the front entrance. LPA Jensen also observed an active fly in the kitchen and an active insect about a half inch in length and 1/4 inch in diameter under the kitchen sink. Photographs were taken of the insects observed.

Continued on LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/26/2022 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20220826123615

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: DATE:
09/14/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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9
Facility plumbing is in disrepair
Licensee did not safeguard resident's personal items
INVESTIGATION FINDINGS:
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On 9/14/22 at approximately 10am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegations. LPA Jensen met with Administrator Edgar Espiritu and explained the purpose of today's visit. The ambient temperature in the facility was observed to to be 79 degrees.

Facility plumbing in disrepair
LPA Jensen tested the water temperature in the bathroom closest to the front door and water temperature measured at 110.7 degrees which falls within the regulatory range of 105-120 degrees. LPA Jensen tested the water temperature in the kitchen which measured at 115.4 degrees which also falls within the required regulatory range. LPA Jensen ran the water in the sink of three bathrooms and the kitchen and did not observe any leaks. LPA Jensen ran the shower that joins 2 resident rooms and did not observe any issues. There was no excessive pooling of water observed in any of the 3 bathrooms that were checked.
Continued on LIC 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20220826123615
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/14/2022
NARRATIVE
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Continued from LIC 9099A...
Based on LPA Jensen's observations of the water pipes in 3 bathrooms and the kitchen and the water temperature check of 1 bathroom and kitchen, the allegation of the facility plumbing being in disrepair is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may be valid, the preponderance of evidence standard has not been met.

Licensee did not safeguard resident's personal items
LPA Jensen confirmed with the Administrator that the facility does not handle money for residents. LPA Jensen interviewed Administrator Edgar Espiritu who stated that not all residents come to the facility with belongings as some are released from the hospital with no belongings and no clothing. In these cases the licensee provides some basic necessities to residents in care. LPA Jensen interviewed resident 1 (R1) and resident 2 (R2). Both residents interviewed denied having any concerns about the facility safeguarding their property. LPA Jensen reviewed the safeguard for property forms.. The safeguard for property tracking logs were observed to be complete. Based on interviews conducted a random sample of safeguards for personal property the allegation of the licensee not safeguarding resident's personal items is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may be valid, the preponderance of evidence standard has not been met.

An exit interview was conducted and a copy of this report along with appeal rights was given to the Edgar Espiritu.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20220826123615
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/14/2022
NARRATIVE
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Continued from LIC 9099....

LPA Jensen reviewed pest control service documentation. The pest control contract provided was undated. Service reports were provided showing that a service was conducted on 8/2/22 and 9/2/22 with exterior and interior service done targeting ants, cockroaches and spiders.

Based on LPA Jensen's observation of insects in the facility and a review of the pest control service documentation provided, the facility is not being kept free of insects and the allegation is SUBSTANTIATED.
A finding of substantiated means that a preponderance of evidence was found in support of the allegation.

Deficiencies are being cited on this day from the California Code of Regulations, Title 22, Division 6.

An exit interview was conducted and a copy of this report alomg with appeal rights was given to Edgar Espiritu.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20220826123615
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/28/2022
Section Cited
CCR
80087(a)(1)
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80087 Buildings and Grounds
...
(1) The licensee shall take measures to keep the facility free of flies and other insects.
This requirement was not met as evidenced by:
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The Licensee agrees to install magnetic screens to doors that do not currently have netting or screens and the Licensee will enter in to a pest control service agreement with interior and exterior service to be provided monthy. Licensee will email a dated and signed pest control contract that includes a service address. Licensee will also email photos of the magnetic screens to CCLD at maja.jensen@dss.ca.gov
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Based on LPA's observation of active insects in front hall, the bathroom located closest to the front entrance and kitchen. This poses a potential health, safety and personal rights risk to residents 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.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5