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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606836
Report Date: 07/08/2025
Date Signed: 07/08/2025 07:46:10 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/01/2025 and conducted by Evaluator Mayra Cota
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250701150003
FACILITY NAME:GOOD SHEPHERD HOMEFACILITY NUMBER:
197606836
ADMINISTRATOR:FEDELITO RUIZFACILITY TYPE:
740
ADDRESS:14812 LA FONDA DRIVETELEPHONE:
(714) 739-1182
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY:6CENSUS: 3DATE:
07/08/2025
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Fidelito RuizTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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9
Facility is in disrepair.
Staff did not ensure medical services were provided.
Facility did not meet food service requirements.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mayra Cota visited the facility to conduct the 10-day complaint investigation regarding the allegations listed above. Upon arrival, LPA met with Fidelito Ruiz, Administrator, and the reason for the visit was explained.

The investigation consisted of the following:

At the time of visit, LPA Cota, obtained copies of staff and resident rosters, conducted a tour of the physical plant with focus on inspecting resident bedroom #4 and resident bathroom #1, conducted record review for Resident #1-4 (R1-R4) and Staff #1-6 (S1-S6) and interviewed S1-S3. Resident menus were also reviewed, and copies of all relevant documents were obtained including facility's Plan of Operation. LPA attempted to conduct interviews with R1-R3, but was unable to due to residents being non-responsive. R4-R6 were not available for interviews due to being away at day program.

Continues on LIC 9099-C
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 28-AS-20250701150003
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GOOD SHEPHERD HOME
FACILITY NUMBER: 197606836
VISIT DATE: 07/08/2025
NARRATIVE
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The investigation revealed the following:

Regarding allegation: Facility is in disrepair.

Interview with S1 revealed that resident bedroom #4 had a hole in the ceiling. S1 interview also revealed, that one of the walls in bathroom #1 was chipped at the bottom and bathroom vent was dirty. S1 interview further indicated, that the repairs and cleaning were completed prior to today’s visit. During visit, LPA observation indicated repairs had been completed for the hole in the ceiling and chipped wall in the bathroom and the vent in the bathroom was cleaned. Based on interview with S1 and LPA observation, the allegation is corroborated; therefore the allegation is SUBSTANTIATED.

Regarding: Staff did not ensure medical services were provided.

Interview with S1 revealed, an appointment for routine medical services for R1 had not been scheduled because family had not signed the declination/acceptance form which would grant or deny permission for R1 to attend the routine medical appointment. Record review conducted during visit revealed, medical appointment for R1 had not been scheduled; however, there was no documentation indicating family’s decline for a medical appointment until it was sent by family on 5/28/25 . Further record review conducted by LPA indicated, facility staff received the declination for the routine medical appointment from family last year on 12/5/24; however, the decline form for this year had not been requested from family by licensee until 5/28/25. Interview with S1 further revealed, R2’s file was missing Immunization record but review conducted by LPA at the time of visit indicated, R2’s immunization record was present in the file. Record review also showed no indication of R2 attending a dental appointment around the anniversary of last years appointment which took place on 6/24/24 or confirmation of an upcoming scheduled appointment. Licensee scheduled dental appointment for R2 at the time of visit via phone call to dental facility. Based on interview with S1 and LPA record review, the allegation is corroborated and therefore the allegation is SUBSTANTIATED.

Continues on LIC 9099-C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/01/2025 and conducted by Evaluator Mayra Cota
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250701150003

FACILITY NAME:GOOD SHEPHERD HOMEFACILITY NUMBER:
197606836
ADMINISTRATOR:FEDELITO RUIZFACILITY TYPE:
740
ADDRESS:14812 LA FONDA DRIVETELEPHONE:
(714) 739-1182
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY:6CENSUS: 3DATE:
07/08/2025
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Fidelito Ruiz, AdministratorTIME COMPLETED:
06:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not ensure staff are adequately trained.
INVESTIGATION FINDINGS:
1
2
3
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5
6
7
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9
10
11
12
13
Licensing Program Analyst (LPA) Mayra Cota visited the facility to conduct the 10-day complaint investigation regarding the allegation listed above. Upon arrival, LPA met with Fidelito Ruiz, Administrator, and the reason for the visit was explained.

The investigation consisted of the following:

At the time of visit, LPA Cota, obtained copies of staff and resident rosters, conducted a tour of the physical plant with focus on inspecting resident bedroom #4 and resident bathroom #1, conducted record review for Resident #1-4 (R1-R4) and Staff #1-6 (S1-S6) and interviewed S1-S3. Resident menus were also reviewed, and copies of all relevant documents were obtained including facility's Plan of Operation. LPA attempted to conduct interviews with R1-R3, but was unable to due to residents being non-responsive. R4-R6 were not available for interviews due to being away at day program.

Continues on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 28-AS-20250701150003
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GOOD SHEPHERD HOME
FACILITY NUMBER: 197606836
VISIT DATE: 07/08/2025
NARRATIVE
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The investigation revealed the following:

Regarding allegation: Staff does not ensure staff are adequately trained.

Record review indicated that S1-S6 have the required job training received during initial hire and through continued education for various topics, including but not limited to Reporting and Documentation, Abuse and Neglect Reporting and Dementia Training. Records indicate staff have the initial (40) hours of training provided during orientation and are required by licensee to continue with training throughout the year. Record review further indicated, S1-S6 have certification through continued education for care and supervision for residents in their care. Record review does not corroborate the allegation.

Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Fidelito Ruiz, Administrator, and a copy of this report was provided during visit.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 28-AS-20250701150003
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GOOD SHEPHERD HOME
FACILITY NUMBER: 197606836
VISIT DATE: 07/08/2025
NARRATIVE
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Regarding allegation: Facility did not meet food service requirements.

Record review and observation conducted by LPA revealed, facility's current menu plan for residents does not offer a variety of foods to meet personal preferences, special dietary needs, food habits and cultural background. Interview with S1 indicated, alternate menu had not been updated nor posted. Based on interview with S1 and LPA record review and observation, the allegation is corroborated and therefore the allegations is SUBSTANTIATED.

Based on LPA’s observations, interviews and record review, the preponderance of evidence standard has been met; therefore, the allegations noted above are found to be SUBSTANTIATED.

Deficiencies were observed and cited per California Code of Regulation Title 22 Division 6. Refer to LIC 9099-D.

Exit interview held with Fidelito Ruiz, Administrator and copy of report and Appeal Rights provided during visit.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 28-AS-20250701150003
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GOOD SHEPHERD HOME
FACILITY NUMBER: 197606836
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/08/2025
Section Cited
CCR
87303(a)
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87303(a) Maintenance and Operation
(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 evidence by:
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Licensee completed repairs prior to today's visit by covering/reparing the hole in bedroom #4, reparing the chipped wall in bathroom #1 and cleaning the vent in bathroom #1.
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Based on interview and observation, resident bedroom #4 had a hole in the ceiling, one of the walls in bathroom #1 was chipped at the bottom and bathroom vent was dirty which poses an immediate health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 28-AS-20250701150003
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GOOD SHEPHERD HOME
FACILITY NUMBER: 197606836
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/08/2025
Section Cited
CCR
87506(b)(13)
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87506(b)(13) Resident Records
(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 needed services. This requirement is not met as evidence by:
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Corrections made during time of visit. Licensee provided LPA with declination for medical services for resident and scheduled dental appoinment via phone call for resident for 8/1/25.
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Based on interview and record review, licensee did not ensure that residents had the proper declination of routine medical appoinment in place and scheduled resident dental appoinment accordingly which poses a potential risk for the health and safety of residents in care.
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Type B
07/22/2025
Section Cited
CCR
87555(b)(5)
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87555 General FoodService Requirements
(b) The following food service requirements shall apply: (5) Meals shall consist of an appropriate variety of foods and shall be planned with consideration for cultural and religious background and food habits of residents. This requirement is not met as evidence by:
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Licensee will create a menu plan with alternative food choices to meet the needs of resident's food habits, preferences and cultural background. Licensee will include a variety of foof items for residents in care by POC due date.
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Based on record review, current menu plan for residents does not offer a variety of foods to meet personal preferences, special dietary needs, food habits and cultural background which poses a potential health and safety risk for residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7