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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005616
Report Date: 09/12/2023
Date Signed: 09/12/2023 03:54:08 PM

Document Has Been Signed on 09/12/2023 03:54 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:ADELFA RUTH BANAGAFACILITY TYPE:
740
ADDRESS:5964 GLEN STREETTELEPHONE:
(209) 478-2170
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 15CENSUS: 13DATE:
09/12/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Edgar EspirituTIME COMPLETED:
04:15 PM
NARRATIVE
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On 9/12/23 at approximately 1:40pm, Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management regarding deficiencies that were brought to the LPA's attention while investigating a separate complaint allegation. Please refer to complaint control number 27-AS-20230814104351. LPA Jensen met with Licensee Edgar Espiritu and explained the purpose of today's visit.

LPA Jensen conducted interviews with 2 staff members and 4 residents while investigating allegations related to the above listed complaint. 1 of 2 staff members and 3 of 4 residents stated that on the weekend of August 8/12/23-8/13/23, 2 residents required critical assistance during meal service however there was no staff in the dining room therefore another resident had to summon staff for help.

Deficiencies are being cited pursuant to the California Code of Regulations, 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 provided.
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/12/2023 03:54 PM - It Cannot Be Edited


Created By: Maja Jensen On 09/12/2023 at 03:07 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: 09/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/13/2023
Section Cited
CCR
87464(f)(4)

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Basic Services
Basic services shall at a minimum include:...
Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing...This requirement was not met as evidenced by:
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The Licensee agrees to submit an attestation by email, by POC due date, to maja.jensen@dss.ca.gov stating that all meal services will be conducted with supervision by staff.
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Based on interviews conducted with staff and residents, on 2 separate occasions residents required critical assistance and there was no staff in the dining room. This poses an immediate 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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