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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397005616
Report Date: 09/12/2023
Date Signed: 09/12/2023 03:50:08 PM

Unsubstantiated


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
08/14/2023 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20230814104351
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: 13DATE:
09/12/2023
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Edgar EspirituTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not allow resident to have visitors
INVESTIGATION FINDINGS:
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On 9/12/23 at approximately 1:40pm, Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to deliver findings for a complaint investigation in to the above listed allegation. LPA Jensen met with Edgar Espiritu and explained the purpose of today's visit.

During the course of the investigation LPA Jensen interviewed 2 staff members, resident 1 who is the subject of this complaint and 3 additional residents. LPA Jensen also received a voice mail from the Ombudsman providing details on their involvement in the allegation. Based on the interviews conducted, only the subject resident advised that he experienced restrictions with visitors. The staff members interviewed and the Ombudsman all stated that R1 had a guest come to the facility but left without visiting due to the facility having residents that were displaying symptoms of COVID-19. Based on the interviews conducted the allegation of staff did not allow resident to have visitors is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it.
An exit interview was conducted and a copy of this report and appeal rights were given to Edgar Espiritu.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
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 4
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
08/14/2023 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20230814104351

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:
09/12/2023
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Edgar EspirituTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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2
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9
Staff does not ensure food of good quality is served to residents in care
INVESTIGATION FINDINGS:
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On 9/12/23 at approximately 1:40pm, Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to deliver findings for a complaint investigation in to the above listed allegation. LPA Jensen met Edgar Espiritu and explained the purpose of today's visit.

During the course of the visit on 8/15/23, LPA Jensen observed expired food in the pantry including but not limited to a box of hamburger helper expiring in January of 2022, canned goods with no dates, tupperware with food that had no dates, wafer ice cream cones that expired 9/2020, spaghetti that expired in January of 2021, spices that expired in 10/2022. During the course of the visit on 9/12/23, LPA Jensen observed rice stored on the kitchen floor in a large tub that was unsanitary. Based on facility observations on 2 occassions the allegation that staff does not ensure food of good quality is served to residents in care is SUBSTANTIATED. A finding og substantiated means that the preponderance of evidence standard has been met.
Continued on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
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 4
Control Number 27-AS-20230814104351
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: 09/12/2023
NARRATIVE
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Defciencies are being cited from pursuant to the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

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: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20230814104351
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: 09/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/26/2023
Section Cited
CCR
87555(b)(9)
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General Food Service Requirements
The following food service requirements shall apply:...
Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement was not met as evidenced by:
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The Licensee agrees to conduct a deep cleaning of the kitchen and add procedures to kitchen staff duties that include monthly self audits for expired food. The Licensee will email the new procedures and photos of kitchen post cleaning to maja.jensen@dss.ca.gov by POC due date.
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Based on LPA's observation of expired food, and unsafe food storage practices during teh course of 2 site visits. This poses a potential risk to the health, safety and personal rights of 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: 09/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4