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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602600
Report Date: 06/08/2022
Date Signed: 06/08/2022 03:26:24 PM


Document Has Been Signed on 06/08/2022 03:26 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 COTTAGE ASSISTED LIVINGFACILITY NUMBER:
198602600
ADMINISTRATOR:MORLOK, NICOLE MFACILITY TYPE:
740
ADDRESS:1218 ROYAL OAKS DRTELEPHONE:
(626) 239-0710
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY:28CENSUS: 18DATE:
06/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Administrator, Aracely ArellanoTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Vasallo conducted an annual required visit. LPA met with Administrator, Aracely Arellano and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, residents' medications and records, food supply, and staff records. The facility cares for elderly residents and is approved for 7 hospice residents. There are currently 0 residents on hospice.

Resident bedrooms were randomly chosen for inspection. All resident rooms are private. Each room has a bed linen, dresser, light, and sufficient closet space. The resident bathrooms have the required grabs bars and non-skid materials in the shower. The hot water was between 105.5 - 111.2 degrees which is within the required 105 - 120 degrees. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances were clean and operating properly. The common areas include the living room, dining room, activity room and outside sitting area. These areas are clean and have the required furniture. Stairways and exit doors are free of any obstruction. There is a screening station at the entrance of the facility which has PPEs and a thermometer to screen visitors. Staff document temperatures daily and require visitors to sign in. Facility currently has at least a 30-day supply of PPEs.

LPA reviewed 3 resident records to confirm emergency contact is updated. 4 staff records were reviewed to confirm health screenings, training and fingerprint clearances. All records were complete. LPA reviewed 3 residents' medications. Medications are documented properly and given as prescribed.

Per California Code of Regulations, Title 22, there were no deficiencies observed during the visit. Exit interview held. A copy of the report was provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022
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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