197606836-10-20-2023-28-AS-JVIS-CWSTMX-20231020145152

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606836
Report Date: 10/20/2023
Date Signed: 10/20/2023 02:52:06 PM

Document Has Been Signed on 10/20/2023 02:52 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	GOOD SHEPHERD HOME		FACILITY NUMBER:	197606836
ADMINISTRATOR:	FEDELITO RUIZ		FACILITY TYPE:	740
ADDRESS:	14812 LA FONDA DRIVE		TELEPHONE:	(714) 739-1182
CITY:	LA MIRADA	STATE: CA	ZIP CODE:	90638
CAPACITY:	6	CENSUS: 6	DATE:	10/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Administrator Fedelito Riuz		TIME COMPLETED:	03:05 PM

NARRATIVE

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Licensing Program Analysts (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Administrator Fedelito Riuz. The following 12 (CARE) tool domains were utilized during the inspection:

Infection Control:

Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. Infection Control Plan not observed

Operational Requirements:

A current Plan of Operation with Dementia Care Plan on file.
Facility is vendorized through East Los Angeles Regional Center
A fire clearance for 6 residents of which (6) may be non ambulatory; (5) may be bedridden.
Hospice care waiver approved for one (1) residents.

Physical Plant/Environment Safety:

Facility is a one story family home with six (6) bedrooms, three (3) bathrooms, living room, kitchen, central air and heating, dining area, gated fire, laundry room, multiple shaded areas located in the front-yard, and an attached garage for storage. The residence is equipped with central air and heating. Fire alarms and sprinkler system operational and inspected up to date.
The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible.
Water temperature readings measured within the required 105 - 120 degrees Fahrenheit.

Staffing:

A total of 5 staff members provide supervision to the residents.
Sufficient staff observed during visit

Continued on LIC 809-C

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GOOD SHEPHERD HOME	FACILITY NUMBER: 197606836
	VISIT DATE: 10/20/2023

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Personnel Records/Staff Training:

Administrator on file is current.
Staff have criminal background clearance and training.
Three (3) staff files were reviewed. Required training observed

Resident Records/Incident Reports:

A total of six (6) resident files were reviewed.
Required postings observed

Planned Activities:

Sufficient space to accommodate both indoor and outdoor activities was observed.
Activities supply observed

Food Service:

Sanitation practices and kitchen cleanliness was observed.
Kitchen has utensils for clients to use and to store their meals

Incident Medical and Dental:

Emergency transportation available
First Aid Kid observed
(6) of (6) Resident medications reviewed

Disaster Preparedness:

Emergency and Disaster Plan LIC 610E is in place.

Residents with Special Health Needs:

Needs and Services Plan and Appraisals are on file. There are no special health needs current being provided

Inspection Tool was completed. Per Title 22 Regulations, a deficiency is being cited (See LIC 809-D).

Exit interview conducted and a copy of this report and appeal rights were provided and discussed.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/20/2023 02:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 10/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87470(c)

Infection Control Requirements

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as there is no infection control plan on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/03/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator to provide Licensing with an Infection Control Plan for review by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC809 (FAS) - (06/04)

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