Shepherd Homes 2

Allegation investigated: Staff mishandled a resident's personal property

On 7-29-2026 at 12:17pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the allegation noted above. LPA met with Administrator Edgar Espiritu and explained the purpose of the visit. During this investigation, LPA conducted interviews with four staff members and four residents in care. LPA also interviewed an additional witness. LPA also reviewed facility file documentation including physician's report, needs and service plan, and inventory sheet for resident1 (R1). Additionally, LPA conducted a facility observation on 7-15-2026 and 7-29-2026 as part of this investigation. Allegation: Staff mishandled a resident's personal property. LPA conducted interviews, record reviews, and observations as noted above. Based on interviews and record reviews, it was revealed that resident1 (R1) previously expressed various personal items missing and mishandled by staff. Interviews conducted did not reveal any corroborated statements of R1 in possession of these items. A review of R1's inventory sheet did not reveal the identified alleged missing and mishandled items. An additional interview with witness1 (W1) further revealed that R1 was not in possession of the alleged missing and mishandled items while residing at facility. {Cont. on 9099C} Unsubstantiated LPA's observation of facility did not reveal additional evidence of staff entering resident rooms and taking personal items out of the rooms or otherwise mishandling resident personal items. As a result, there is not a preponderance of evidence to conclude that staff mishandled a resident's personal property, therefore, this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means he allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator and a copy of this report was provided. Appeal rights provided.the state’s words, verbatim · CDSS document, Jul 29, 2026 · control 27-AS-20260715143856

Allegation investigated: Resident sustained 2nd and 3rd degree burns due to lack of supervision Staff did not obtain medical care for resident Staff do not ensure resident's showering needs are met

On 7-29-2026 at 9:52am, Licensing Program Analyst (LPA) Michael Bilger arrived at the facility unannounced to deliver and discuss findings for the allegations noted above. LPA met with Administrator Edgar Espiritu and explained the purpose of the visit. During this investigation, LPA conducted interviews with four staff members, two residents in care and one additional witness. Additionally, LPA reviewed facility file documentation including incident reports, medication log sheets, physician’s report, progress notes, and bath/shower schedule. LPA also reviewed additional medical records as part of this investigation. Allegation: Resident sustained 2nd and 3rd degree burns due to lack of supervision. LPA conducted interviews and record reviews as noted above. Based on interviews and record reviews it was determined that on 4-29-2026 at approximately 11:00am the facility cook handed a hot cup of noodle soup to resident1 (R1) and left the room. Interviews conducted further revealed that an overbed table was not utilized for support and safety. {Cont. on 9099C} Substantiated Additionally, it was revealed that a caregiver was not present to assist and ensure safety given resident was not utilizing an overbed table. After the soup was handed to R1, R1 spelt the soup on her upper left thigh area at approximately 11:35am which initially caused redness. It was later revealed on 5-1-2026 that R1 sustained a 2nd degree burn. As a result, there is a preponderance of evidence to conclude that staff did not utilize an appropriate supervision procedure given the knowledge that R1 was not using an overbed table or other device to support R1’s self feeding of a hot liquid food item, resulting in risk and eventual injury to R1, therefore, this allegation is SUBSTANTIATED. Allegation: Staff did not obtain medical care for a resident. LPA conducted interviews and record reviews as noted above. Based on interviews and record reviews it was determined that on 4-29-2026 at approximately 11:00am the facility cook handed a hot cup of noodle soup to resident1 (R1) and walked away. After the soup was handed to R1, R1 spelt the soup on her upper left thigh area at approximately 11:35am which initially caused redness. It was further revealed that after learning of the incident, staff did not initially call 911 for immediate evaluation and determination for treatment. At approximately 3-3:30pm on 4-29-2026, an outside medical professional observed the redness and gave a verbal direction to apply ointment. It was later revealed on 5-1-2026 that R1 sustained a 2nd degree burn. Additional interviews revealed that given this incident, 911 was not called and should have been called. As a result, there is a preponderance of evidence to conclude that staff did not utilize the regulatory requirement of calling 911 as noted in Section 87465(g) when the injury and imminent threat to health occurred, therefore, this allegation is SUBSTANTIATED. Allegation: Staff do not ensure resident’s showering needs are met. LPA conducted interviews and record reviews as noted above. Based on interviews and record reviews it was determined that R1 was admitted to facility in March 2026. Shower records revealed that R1 was offered showers on 3-20-2026, 3-28-2026, 4-5-2026, and 4-10-2026 with refusals by R1 noted. Records did not reveal additional shower offerings beyond 4-10-2026 and up to R1’s discharge on or about 4-30-2026. Furthermore, records did not reveal additional shower offerings after R1 refused. A review of R1’s physician’s report revealed that R1 was unable to bathe self and required assistance. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. {Cont. on 9099C} The following deficiencies were observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22, Division 6, and Health and Safety Codes. Failure to correct the deficiencies may result in additional civil penalties. An immediate civil penalty in the amount of five-hundred dollars ($500) was issued in addition to citation due to a violation resulting in a severe injury. At the time of the complaint visit, the issuance of an additional Civil Penalty was still being determined, and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(f). An exit interview was conducted with Administrator , and a copy of this report was provided. Appeal rights provided. LIC 811 provided.the state’s words, verbatim · CDSS document, Jul 29, 2026 · control 27-AS-20260506142813

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(e) · Plan of correction due date: Jul 30, 2026

1569.312 Basic Service Requirements. (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. This requirement was not met as evidenced by: Based on interviews and record reviews, Licensee did not ensure adequate level of supervision for R1 resulting in a severe injury to R1. This posed an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Jul 29, 2026

Plan of correction: Licensee to ensure completed staff training on proper supervision of residents in care. Training date to be submitted to LPA by POC due date. Proof of completed training to be sent to LPA no later than 8/14/2026. Licensee to develop and submit a protocol outlining proper supervision procedures of residents. Protocol to include various examples of scenarios which constitute certain levels of supervision. Protocol to be submitted to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Jul 30, 2026

87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health…This requirement was not met as evidenced by: Based on interviews and record reviews, Licensee did not ensure the immediate call to 911 after learning of hot soup spilling onto R1’s thigh area. This posed an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Jul 29, 2026

Plan of correction: Licensee will ensure completed staff training on Section 87465(g). Training to include proper response to emergencies and when to call 911. Training date to be submitted to LPA by POC due date. Proof of completed training to be submitted to LPA no later than 8/14/2026. Licensee to develop and submit a protocol outlining procedures of when to call 911. Protocol to include various examples of scenarios which constitute a call to 911 Protocol to be sent to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.312(a) · Plan of correction due date: Aug 7, 2026

1569.312 Basic Service Requirements. (a) Care and supervision as defined in Section 1569.2. This requirement was not met as evidence by: Based on record reviews and interviews, Licensee did not ensure additional offerings of showers and shower assistance to R1 in relation to length of R1’s residency at facility. This posed a potential health, safety, and resident rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 29, 2026

Plan of correction: Licensee to develop and submit a plan outlining how staff will consistently meet and/or attempt to meet residents’ showering needs and other assistance with activities of daily living needs. Plan to be submitted to LPA by POC due date. Licensee will read Section 1569.2 and submit a written declaration of understanding of the definition of “care and supervision” to LPA by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced annual visit on this date. LPA met with Ruth and explained the purpose of the visit. The facility is on two separate parcels with connecting gate and a shared common area. LPA inspected physical plant including but not limited to kitchen, bedrooms, bathrooms, living and dining room area. LPA observed the facility. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 118 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. Fire extinguishers and smoke detectors are current and in compliance with fire safety. Carbon dioxide monitor present. Fire drill was conducted on 9/20/2025 LPA observed centrally stored medications. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed resident and staff files, including criminal record clearances. All staff today are associated to the facility. First aid kit was checked and is complete. Per California Code of Regulations, Title 22 Division 6, Chapter 8, No deficiencies were cited during this visit. Exit interview held and a report given at the conclusion of the visitthe state’s words, verbatim · CDSS document, Nov 3, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst Albert Johnson arrived to conduct an unannounced case management visit for an incident reported to the department. LPA conducted a file review for R1 with the assistance of the Administrator. R1's LIC 602 was current. The Department conducted a case management visit to investigate a special incident report received. The incident report detailed that, R1 was sent out to the ER for generalized weakness and off her baseline. R1 has since returned to the facility with no new orders. R1 requested to be returned back to Shepherd home in lieu of a rehabilitation center. No citation given. Exit interview.the state’s words, verbatim · CDSS document, Sep 16, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced annual visit on this date. LPA met with Edgar Espiritu and explained the purpose of the visit. The facility is on two separate parcels with connecting gate and a shared common area. LPA inspected physical plant including but not limited to kitchen, bedrooms, bathrooms, living and dining room area. LPA observed the facility. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 118 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. Fire extinguishers and smoke detectors are current and in compliance with fire safety. Carbon dioxide monitor present. Fire drill was conducted on 9/20/2024 LPA observed centrally stored medications. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed resident and staff files, including criminal record clearances. All staff today are associated to the facility. First aid kit was checked and is complete. Per California Code of Regulations, Title 22 Division 6, Chapter 8, No deficiencies were cited during this visit. Exit interview held and a report given at the conclusion of the visit.the state’s words, verbatim · CDSS document, Nov 18, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced annual visit on this date. LPA met with Edgar Espiritu and explained the purpose of the visit. LPA inspected physical plant including but not limited to kitchen, bedrooms, bathrooms, living and dining room area. LPA observed the facility. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 115 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. Fire extinguishers and smoke detectors are current and in compliance with fire safety. Carbon dioxide monitor present LPA observed centrally stored medications. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed resident and staff files, including criminal record clearances. All staff today are associated to the facility. First aid kit was checked and is complete. Per California Code of Regulations, Title 22 Division 6, Chapter 8, No deficiencies were observed during this visit. Exit interview held and a report given at the conclusion of the visit.the state’s words, verbatim · CDSS document, Oct 17, 2023