197610302-8-3-2022-31-AS-APAA-CGXQP8-20220803122020

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610302
Report Date: 08/03/2022
Date Signed: 08/03/2022 12:21:23 PM

Document Has Been Signed on 08/03/2022 12:21 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	GOOD SHEPHERD CARE INC		FACILITY NUMBER:	197610302
ADMINISTRATOR:	SANTOS, RIE ULYSSES		FACILITY TYPE:	740
ADDRESS:	25336 VIA PACIFICA		TELEPHONE:	(818) 428-5352
CITY:	VALENCIA	STATE: CA	ZIP CODE:	91355
CAPACITY:	6	CENSUS: 5	DATE:	08/03/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	James Contreras, Applicant/Licensee		TIME COMPLETED:	12:45 PM

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At 9:05am Licensing Program Analyst (LPA), Angela Panushkina conducted an announced Pre-Licensing visit to the above facility and met with Applicant/Licensee, James Contreras. This is a change of ownership application from (Facility #197607995) to (Facility ##197610302). LPA conducted an entrance interview with the Applicant/Licensee. At the time of this visit LPA observed and assessed ) five (5) residents present in the facility. All residents appear to be clean and groomed. Fire Clearance dated 06/09/2022 was received for two (2) non-ambulatory and four (4) bedridden resident. The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. The facility is a single-story building. Today's site visit consisted of LPA touring the physical plant inside and outside and observed the following:

The facility has a total of five (5) bedrooms, five (5) of which are designated for resident use. Resident bedrooms were observed to be appropriately furnished. There are two (2) bathrooms in the facility and were observed to have non-skid mats and appropriate grab bars installed. The facility will have awake staff at night.

The common areas (living room, kitchen and dining areas) were appropriately furnished and lighting was adequate. The living room has a television and comfortable furniture. Resident and staff records and the medications are stored in a locked cabinet in the kitchen. The fire extinguisher is also located in the kitchen and was observed to be fully charged and was last serviced on 09/27/21. LPA observed fire sprinkles throughout the facility. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 11:45am they were tested and observed to be operational. At 11:50am the hot water was tested and measured 105°F. There is a functioning telephone on the premises. An emergency exit plan/sketch is posted by the entrance wall with other posting requirements.

Facility appears to be clean, in good repair and kept at a comfortable temperature of 75°F. Appliances in the kitchen appeared to be functional. Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022

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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GOOD SHEPHERD CARE INC	FACILITY NUMBER: 197610302
	VISIT DATE: 08/03/2022

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LPA observed enough sufficient supply of two (2) days perishable foods and one (1) week of non-perishable foods on premises. The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all doors. Plan of operation for dementia residents was also discussed with the Applicant/Licensee.

At approximately, 12:00pm LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. There are no bodies of water.

Laundry area is located in an attached garage and kept locked and inaccessible to residents. Extra PPE supplies and food storage was also observed.

Component III was conducted with the Applicant/Licensee.

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) and be notified by the CAB Analyst when your license has been approved.

Exit interview was conducted and with a copy of this report was provided to the Applicant/Licensee.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022

LIC809 (FAS) - (06/04)

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