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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606836
Report Date: 09/27/2024
Date Signed: 09/27/2024 04:17:17 PM


Document Has Been Signed on 09/27/2024 04:17 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:FEDELITO RUIZFACILITY TYPE:
740
ADDRESS:14812 LA FONDA DRIVETELEPHONE:
(714) 739-1182
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY:6CENSUS: 6DATE:
09/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:Elena Baydel - CaregiverTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1-Year visit at the facility. LPA was greeted by Elena Baydel, caregiver for the facility, and explained the purpose of the visit. There are currently 6 residents who are currently living in the facility.

During visit, LPA conducted a tour of the facility. There are four (4) resident rooms located within the facility, a kitchen, a dining room, a staff bedroom, a staff bathroom, client bathroom, two (2) sheds outdoors that contain miscellaneous supplies, and an attached garage the contains the facility's washer and dryer machines. The facility was observed to be clean and in good repair.

Due to time constraints, the annual inspection will need to be completed at a later time. Exit interview held and a copy of this report was provided to Elena Baydel.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik ZaragozaTELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024
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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