SHEPHERD'S INN

Official classification

Type A

Official code

87309(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. (1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, & record review, the licensee did not comply with the section cited above due to windex window cleaner in a common bathroom, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/30/2026 Plan of Correction Administrator will have cleaner removed and placed in locked storage area.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(a) 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 Based on observation, the licensee did not comply with the section cited above due to the refrigerator having spillage throughout & outlet cover needing to be replaced in garage pantry, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/05/2026 Plan of Correction Administrator will have corrections made and verification will be sent to the Dept by POC due date.

Official classification

Type B

Official code

87303(e)(5)(A)

Regulation authority

CCR

What the official deficiency says

(5) Slip-resistant mats, strips, or flooring shall be used in all bathtub and shower floors. (A) All slip-resistant mats, strips, or flooring shall be in good repair and maintain slip-resistant properties. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above due to LPA observing non-slip mat to have rubber/latex stripped, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/05/2026 Plan of Correction Administrator will get new mats. Verification will be provided to the Dept by POC.

Official classification

Type B

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation & interview, the licensee did not comply with the section cited above due to LPA observing expired food in jars and discolored pasta in jars in garage pantry, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/05/2026 Plan of Correction

Official classification

Type A

Official code

1569.311

Regulation authority

HSC

What the official deficiency says

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in that no carbon monoxide detectors were found working at the facility which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/25/2025 Plan of Correction Licensee to provide proof of purchase and placement of working Carbon Monoxide detector.

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in that water temperature was measured at 139.6 degrees F which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/23/2025 Plan of Correction Licensee to measure water temperature regularly. This was fixed before LPA left the facility

Official classification

Type B

Official code

87465(c)(3)

Regulation authority

CCR

What the official deficiency says

(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: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement is not met as evidenced by: Deficient Practice Statement Based on records review, the licensee did not comply with the section cited above in 5 out of 5 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/26/2025 Plan of Correction Licensee to get all records updated for all residents as they continue to be seen at the doctor. There are regular visits made, but there are no updates to the Assessment form for the records. Updates to needs for PRNs must be noted by doctor.

Official classification

Type B

Official code

87463(i)

Regulation authority

CCR

What the official deficiency says

(i) When there is significant change in condition, as defined in Section 87101, Definitions, or once every 12 months, whichever occurs first, the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's representative, if applicable, and appropriate facility staff, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 5 out of 5 resident files, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/26/2025 Plan of Correction Licensee to get corrected assessments from the doctor, to keep the residents condition as current as possible. Updates to files were not kept up to date, and were more than a year old.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. During the annual inspection on 7/9/24 Licensee stated the sprinkler alarm had not been serviced for a few years and the smoke detectors were removed because they are too loud.

Official plan of correction

POC Due Date: 07/30/2024 Plan of Correction Licensee stated they would add smoke alarms to the facility and as of 7/27/24 there were new smoke alarms added to the facility.

Official classification

Type A

Official code

87307(d)(2)

Regulation authority

CCR

What the official deficiency says

(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation & interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed garage to not be maintained and is accessible to residents.

Official plan of correction

POC Due Date: 07/30/2024 Plan of Correction Licensee will provide a plan/procedure to clean garage. Verificaiton garage has been cleaned will be provided by 8/6/24 to LPA.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation & interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. During the visit on 7/9/24 LPA observed cleaning supplies & toxins to be unlocked and accessible under the kitchen sink and a cabinet on the side of the sink.

Official plan of correction

POC Due Date: 07/30/2024 Plan of Correction on 7/27/24 LPA observed cleaning supplies to be removed from under the sink. The cabinet on the side of the sink will be locked and verification will be sent to LPA.

Official classification

Type A

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation & interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed non-perishable food items to not be kept in clean area away from rodent droppings. LPA observed food items in refrigerators to not be properly labeled.

Official plan of correction

POC Due Date: 07/30/2024 Plan of Correction Licensee will put a plan/procedure will be put into place and verification will be sent to LPA.

Official classification

Type A

Official code

87555(b)(22)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (22) Adequate space shall be maintained to accommodate equipment, personnel and procedures necessary for proper cleaning and sanitizing of dishes and other utensils. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation & interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed additional kitchen area to be kept in the garage which is used for cooking fish according to the Licensee. LPA observed kitchen to be kept unclean which does not prevent rodents and insect causing items in the garage to not be clean or sanitized.

Official plan of correction

POC Due Date: 07/30/2024 Plan of Correction Licensee will put a plan/procedure will be put into place on how to maintain kitchen in the garage, and verification will be sent to LPA.

Official classification

Type A

Official code

87555(b)(9)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation & interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed a container with rice to be been chewed through by a rodents leaving the rice to be contaminated. Disposable cups were also contaminated due to being chewed by rodents.

Official plan of correction

POC Due Date: 07/30/2024 Plan of Correction Licensee will put a plan/procedure will be put into place and verification will be sent to LPA.

Official classification

Type A

Official code

87555(b)(27)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation & interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed kitchen in garage to be contaminated with droppings from rodents, dirty dishes and trash were in garage.

Official plan of correction

POC Due Date: 07/30/2024 Plan of Correction Licensee will put a plan/procedure will be put into place how to prevent rodent and insects from kitchen in the garage, and verification will be sent to LPA.

Official classification

Type A

Official code

87555(b)(28)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation & interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Due to food being kept in the garage it is considered contaminated and needs to be maintained.

Official plan of correction

POC Due Date: 07/30/2024 Plan of Correction Licensee will put a plan/procedure will be put into place to prevent food items from being contaminated, and verification will be sent to LPA.

Official classification

Type A

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation & interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed a sample of resident files which did not have completed centrally stored medication logs.

Official plan of correction

POC Due Date: 07/30/2024 Plan of Correction Licensee will put a plan/procedure will be put into place to maintain resident's medication log and verification will be sent to LPA.

Official classification

Type A

Official code

97355(e)(1)(2)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/30/2024 Plan of Correction Staff are not to return to the facility until proper clearance and association to the facility has been completed. Licensee will provide verification to LPA.

Official classification

Type B

Official code

87307(a)(2)(B)

Regulation authority

CCR

What the official deficiency says

(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation & interview, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed staff using R1's room as common use to take trash to the outside bins.

Official plan of correction

POC Due Date: 08/06/2024 Plan of Correction Licensee will put a plan/in place which will prevent the staff from using R1's room to exit facility to throw away trash, and verification will be sent to LPA.

Official classification

Type B

Official code

87506(b)(13)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (13) Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or the services he needs. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA did not observe proper documentation in resident's files regarding a change in status.

Official plan of correction

POC Due Date: 08/06/2024 Plan of Correction Licensee will maintain all resident files and the plan to maintain files will be sent to LPA.

Official classification

Type A

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation & interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed expired foods and food not labeled properly.

Official plan of correction

POC Due Date: 08/16/2023 Plan of Correction Staff will send a procedure to be put in place to prevent expired food being stored in the facility.

Official classification

Type A

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed Centrally Stored Medication Log to not be completed properly. Log did not have a start date.

Official plan of correction

POC Due Date: 08/16/2023 Plan of Correction Staff will be trained to complete log in it's entirety.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation & interview, the licensee did not comply with the section cited which poses an immediate health, safety or personal rights risk to persons in care. LPA observed garage door to be unlocked which had knives accessible to residents. One drawer in the kitchen was unlocked which had scissors accessible to residents.

Official plan of correction

POC Due Date: 08/16/2023 Plan of Correction Scissors will be removed from kitchen drawer and notice will be given to staff to inform garage door will remain locked at all times. Copy of notice will be provided to LPA.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation & interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed bleach and other cleaning products under an unlocked kitchen sink.

Official plan of correction

POC Due Date: 08/16/2023 Plan of Correction Cleaning supplies will be removed from under the sink. Picture will be sent to LPA.

Official classification

Type B

Official code

87555(b)(9)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Garage area used to cook certain foods needs to be free from clutter, cleaned, and maintained. Dirty dishes and food not properly stored is left out which can attract rodents.

Official plan of correction

POC Due Date: 08/25/2023 Plan of Correction Clean and organize. Pictures will be sent to LPA.

Official classification

Type B

Official code

87555(b)(27)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed garage area used to store food needs to be clutter free in order to prevent pests. Outside refrigerator used to store resident's food needs to be cleaned.

Official plan of correction

POC Due Date: 08/25/2023 Plan of Correction Clean and organize. Pictures will be sent to LPA.

Official classification

Type B

Official code

87555(b)(28)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation & interview, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed an open package of bacon to be stored with a open package of sliced cheese (raw meat with dairy). Neither item was stored properly causing contamination.

Official plan of correction

POC Due Date: 08/25/2023 Plan of Correction Staff will properly store opened items. Pictures will be sent to LPA.

Official classification

Type B

Official code

1569.695(a)

Regulation authority

HSC

What the official deficiency says

(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above ] which poses/posed a potential health, safety or personal rights risk to persons in care. Facility was not able to provide an emergency/disaster plan for the facility.

Official plan of correction

POC Due Date: 08/25/2023 Plan of Correction Facility will submit plan to LPA.

Official classification

Type A

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

87307-Personal Accommodations and Services-(d) The following space and safety provisions shall apply to all facilities:(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Based upon observation the Licensee failed to keep both the exterior and interior passage way to an emergency exit free from obstruction This poses an immediate Health, Safety and/or Personal Rights risk to Residents in care.

Official plan of correction

LIcensee agrees to remove the obstructions by all passageways by COB on 3/7/2022. Licensee will send photos to LPA when POC is complete.

Deadline recorded: Mar 7, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309 (a)- Storage Space-Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced By: Based upon observation the Licensee failed to keep disinfectans and cleaning solutions stored inaccessible to residents in care This poses an immediate Health, Safety and/or Personal Rights risk to Residents in care.

Official plan of correction

Licensee locked disinfectancts and cleaning solutions during site visit. POC completed.

Deadline recorded: Mar 7, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

87465(h)(2)-Incidental Medical and Dental Care-following requirements shall apply to medications which are centrally stored:(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees. This requirement is not met as evidenced by: Based upon observation and interview the Licensee failed to keep medication centrally stored and locked so that it is no accessible to 5 of 5 residents in care. This poses an immediate Health, Safety and/or Personal Rights risk to Residents in care.

Official plan of correction

LIcensee agrees to replace the lock where medications are kept. THis will be done no later than 3/7/2022

Deadline recorded: Mar 7, 2022. A deadline is not proof that correction was completed.