Inspection visit

Routine inspectionAugust 15, 2023

SHEPHERD'S INNLicense 2752008678 citations on this visit

8 citations recorded

Inspector’s narrative

What the inspector wrote

On 8/15/2023 at 12:31 p.m. Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to conduct an annual inspection. LPA was greeted by staff. Administrator Lita Williams was contacted but will not be able to come to the facility. RJ (Marino) Pascual was contacted and arrived at the facility later. LPA toured the facility inside and out. Facility currently has 6 residents. Each resident has their own bedroom with a door leading to outside for emergency purposes, doors have alarms. LPA observed residents interacting with staff, watching TV, and in their bedrooms. LPA observed facility to have sufficient perishable and non-perishable food items. LPA observed some canned food items to be expired. LPA observed food at facility to not be labeled properly. LPA was not able to distinguish between residents’ food and live in staff food. LPA observed one drawer in the kitchen had scissor which were not locked. Garage/storage door was not locked, this gave residents access to knives. LPA observed cleaning supplies under the kitchen sink to not be locked. Sample of staff files were reviewed, and current training is missing for staff. Resident’s files were reviewed, emergency contact information needs to be completed and up to date with current doctor and dentist contact information. LPA observed centrally stored medication log to not be complete. Facility needs a Plan of Operation, Plan of Operation for Dementia, Disaster Plan, Infection Control Plan to be readily available at the facility. Exit interview was conducted. A copy of LIC809, 809D, and appeal rights were provided to staff RJ (Marino) Pascual

Citations

8 citations recorded^*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

1569.695(a)Type B
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.
87465(a)(6)Type A
Maintain records of centrally stored medication dosages
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.
87555(b)(27)Type B
Kitchen sanitation against contamination sources
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.
87555(b)(28)Type B
Immediate disposal of contaminated food
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.
87555(b)(8)Type A
Food quality controls and rejected damaged goods
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.
87555(b)(9)Type B
Food handling safeguards during storage and service
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.
87705(f)(1)Type A
Notify agency before locking doors or gates
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.
87705(f)(2)Type A
Fire approval and staff access to unlock systems
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.

FAQ · About this visit

Common questions about this visit

What happened during the August 15, 2023 inspection of SHEPHERD'S INN?

This was an inspection of SHEPHERD'S INN on August 15, 2023. 8 citations were issued: 4 Type A (serious) and 4 Type B.

Were any citations issued to SHEPHERD'S INN on August 15, 2023?

Yes, 8 citations were issued (4 Type A, 4 Type B). The first citation was for: "Based on observation, interview, record review, the licensee did not comply with the section cited above ] which poses/p..."

What type of inspection was this?

This was an inspection. Inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLD View original report

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Data from CCLD public records. Last updated July 20, 2026. If you believe any information is inaccurate, report it here.

Routine inspection·August 15, 2023