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Inspection visit

Routine inspection (multi-day)

SHEPHERD'S INNLicense 27520086712 citations on this visit
12 citations recorded

Inspector’s narrative

What the inspector wrote

On 7/27/24 Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to complete the annual inspection. LPA met with Licensee Lita Williams. On 7/9/24 LPA observed the following deficiencies: Smoke detectors were not present in the home, Administrator was not able to provide verification the sprinkler system is in working condition. Gardening tools were in an unlocked drawer in kitchen which are accessible to residents in care. Toxins and cleaning supplies were stored in a cabinet under the sink and in a cabinet next to the sink which was unlocked. The garage also has cleaning supplies which was not locked. Canned food and additional refrigerators are stored in the garage area which is not clean and has rodent droppings throughout the garage. Garage is used to store food which is not being maintained. Garage area used for additional kitchen is not being maintained. Food is not being stored or labeled properly. Medications are not being logged on the centrally stored medication log. There are no audio alarms on the exits and dementia residents reside in the facility. Staff use R1's room to go outside to throw the trash. Staff member S1 was at the facility without being properly associated to the facility. LPA observed staff at the facility. Staff member S2 was on the staff schedule and was working NOC shift according to Licensee. Licensee will provide insurance verification by 8/6/24. Citations were issued per Title 22. Exit interview was conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to Administrator Lita Williams.

Citations

12 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.

  • 87307(d)(2)Type A

    Facility maintenance and healthful environment

    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.

  • 87555(b)(22)Type A

    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.

  • 87202(a)Type A

    Maintain fire clearance before retaining specified persons

    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.

  • 87307(a)(2)(B)Type B

    Prohibition on using other rooms as bedrooms

    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.

  • 87309(a)Type A

    Ensure hazardous items are locked and not unattended

    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.

  • 87465(a)(6)Type A

    Maintain records of centrally stored medication dosages

    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.

  • 87506(b)(13)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. LPA did not observe proper documentation in resident's files regarding a change in status.

  • 87555(b)(27)Type A

    Kitchen sanitation against contamination sources

    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.

  • 87555(b)(28)Type A

    Immediate disposal of contaminated food

    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.

  • 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 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.

  • 87555(b)(9)Type A

    Food handling safeguards during storage and service

    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.

  • 97355(e)(1)(2)Type A

    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.

FAQ · About this visit

Common questions about this visit

What happened during the July 27, 2024 inspection of SHEPHERD'S INN?

This was an other inspection of SHEPHERD'S INN on July 27, 2024. 12 citations were issued: 10 Type A (serious) and 2 Type B.

Were any citations issued to SHEPHERD'S INN on July 27, 2024?

Yes, 12 citations were issued (10 Type A, 2 Type B). The first citation was for: "Based on observation & interview, the licensee did not comply with the section cited above which poses an immediate heal..."

What type of inspection was this?

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

SourceView on CCLDView original report

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