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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610302
Report Date: 11/13/2023
Date Signed: 11/13/2023 03:45:06 PM


Document Has Been Signed on 11/13/2023 03:45 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 INCFACILITY NUMBER:
197610302
ADMINISTRATOR:SANTOS, RIE ULYSSESFACILITY TYPE:
740
ADDRESS:25336 VIA PACIFICATELEPHONE:
(818) 428-5352
CITY:VALENCIASTATE: CAZIP CODE:
91355
CAPACITY:6CENSUS: 6DATE:
11/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Jorge AquinoTIME COMPLETED:
03:54 PM
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Licensing Program Analyst (LPA) Abeye Duguma met with Jorge Aquino for a One (1) Year Required visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at 10:00am and the following was noted:

The facility has a total of five (05) bedrooms and two (02) bathrooms. The facility is fire cleared for two (2) non-ambulatory and four (4) bedridden residents. The facility is currently occupying six (06) non-ambulatory residents.

The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. The garage is currently being used for storage. Laundry detergents, cleaning agents and other toxins are locked away.

Kitchen is sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents. Living and dining room furniture were also checked.

The living and dining room are neat and clean. The facility maintains a comfortable temperature at 75°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher is located near the dining area, observed to be full and last purchased on 09/22/2023.

(continued on LIC 809-C)

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2023
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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