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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602600
Report Date: 07/14/2023
Date Signed: 07/14/2023 03:39:01 PM

Document Has Been Signed on 07/14/2023 03:39 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: 13DATE:
07/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator- Kathryn M Klein TIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced annual visit. Upon arrival LPA met with Sister Juanita and was shortly directed to Administration Offices, where LPA shortly after met with CEO/ Executive Director of Santa Teresita/ 'Sister Mary Estelle' Kathryn M Klein and explained the reason for the visit. LPA used the CARE TOOL to evaluate the facility. The facility cares for elderly residents and is approved for 7 hospice residents. There are currently 0 residents on hospice.

During today's visit LPA requested a copy of staff and resident roster. LPA Calderon and Sister Mary Estelle met with Maintenance staff Miguel Gonzalez at 9:35am who assisted on todays visit . LPA toured facility premises. Resident bedrooms were randomly chosen for inspection Room #'s: C4, C10, C20, and C25. All resident rooms are private. Each room has signal systems, internet and telephone services, 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 111.3-115.5 degrees which is within the required Title 22 regulations.The kitchen was inspected. There is sufficient perishable and non-perishable food, extra food in 2nd floor storage room with extra refrigerators and freezers. All the appliances were clean and operating properly. The common areas include the living room, dining room, activity room and outside sitting area (shaded area observed). These areas are clean and have the required furniture for residents in care. Two electric fireplace observed one in living room and one in dining area that are securely fenced and turns on to provide lighting but no heat distributed. Stairways and exit doors are free of any obstruction. 1st and second floor storage corridor is inaccessible to residents (staff card key is needed), rooms contain: extra food,PPE, extra linen and towels, housekeeping supplies, storage items and emergency supplies.

LPA reviewed 3 resident records and 3 staff records were reviewed to confirm health screenings/tb, training and fingerprint clearances. All records were complete.

Continuation 809-C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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 COTTAGE ASSISTED LIVING
FACILITY NUMBER: 198602600
VISIT DATE: 07/14/2023
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LPA Calderon alongside with Cecilia Cuesta - RN reviewed a total of 5 medication. Medications are documented properly and given as prescribed. Medications were locked and inaccessible to residents in care.

LPA interviewed a total of 2 residents and a total of 3 staff.

Administration Certificate for Klein expires on 12/23/2024. Carbon Monoxide was tested. Hard wired Smoke Alarms inspection test was done on 6/25/23 using INTEC company. Pull system Fire Alarms are hard wired through the Fire Department of Monrovia. Fire extinguishers were observed throughout the facility and were charged/serviced. Liability Insurance Expires on 6/15/2024.

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.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023
LIC809 (FAS) - (06/04)
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