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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606836
Report Date: 10/04/2024
Date Signed: 10/04/2024 03:44:16 PM

Document Has Been Signed on 10/04/2024 03:44 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:GOOD SHEPHERD HOMEFACILITY NUMBER:
197606836
ADMINISTRATOR/
DIRECTOR:		FEDELITO RUIZFACILITY TYPE:
740
ADDRESS:14812 LA FONDA DRIVETELEPHONE:
(714) 739-1182
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 6CENSUS: 6DATE:
10/04/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:44 PM
MET WITH:Elena Baydel - CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Licensing Program Analyst (LPA) Erik Zaragoza conducted a subsequent unannounced Required 1-year annual continuation visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Fedelito Ruiz, administrator for the facility, and explained the purpose of the visit. There are six residents residing within the home.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs.

Infection Control:

· Infection control practices were observed.


· Infection control plan is on file.

Physical Plant/Environment Safety:

· The facility is a single-story home located in a residential neighborhood. It is licensed for a capacity of six (6) residents, six (6) of which may be non-ambulatory, five (5) of which may be bedridden, and a hospice waiver approved for one (1) resident. The facility consists of a kitchen and dining room, a living room, an office area, three (3) restrooms, six (6) bedrooms, and a backyard area that contains a shaded area. The facility was observed to be in good repair.


· The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. The facility has two (2) fully charged fire extinguishers in the facility.
· Water temperature readings for one of the bathrooms in the home did not fall within the required range of 105 - 120 degrees Fahrenheit.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GOOD SHEPHERD HOME
FACILITY NUMBER: 197606836
VISIT DATE: 10/04/2024
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Operational Requirements:

· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for a capacity of six (6) residents, six (6) of which may be non-ambulatory, five (5) of which may be bedridden, and a hospice waiver approved for one (1) resident.


· Care and supervision to meet the clients’ needs was observed.

Staffing:

· Six (6) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Five (5) staff files were reviewed for criminal background clearance and training.


· All staff records reviewed have health a health screening with a Tuberculosis clearance, and all staff have First Aid/CPR trainings that are active.
· The administrator’s certificate expires on 1/29/2025.

Resident Rights/Information:

· Physician orders were reviewed for five (5) resident files.

· Medications were also reviewed for five (5) residents.

Resident Records/Incident Reports:

· Five (5) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GOOD SHEPHERD HOME
FACILITY NUMBER: 197606836
VISIT DATE: 10/04/2024
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Food Service:

· The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

Incident Medical and Dental:

· All residents have an Appraisal/Needs and Services Plan on file.

· Staff training was on file.

Disaster Preparedness:

· Emergency and Disaster Plan was publicly posted and found within the facility.

· The last emergency and disaster drill was conducted on 9/2/2024.

Planned Activities:

· Sufficient Space is provided to accommodate both indoor and outdoor activities.

· Sufficient equipment and supplies are provided to meet the requirements of the activity program.

Residents with Special Health Care Needs:

· There is an adequate number of staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her appraisal.

Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were observed during the visit. Exit interview held and a copy of the report was provided.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024
LIC809 (FAS) - (06/04)
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