198602600-5-31-2024-28-AS-BPEA-D5SR6J-20240531124449

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602600
Report Date: 05/31/2024
Date Signed: 05/31/2024 12:45:03 PM

Document Has Been Signed on 05/31/2024 12:45 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	GOOD SHEPHERD COTTAGE ASSISTED LIVING		FACILITY NUMBER:	198602600
ADMINISTRATOR:	KLIEN,KATHRYN		FACILITY TYPE:	740
ADDRESS:	1218 ROYAL OAKS DR		TELEPHONE:	(626) 239-0710
CITY:	MONROVIA	STATE: CA	ZIP CODE:	91016
CAPACITY:	28	CENSUS: 17	DATE:	05/31/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:24 AM
MET WITH:	Sister Magdalene Grace - Care Coordinator Nathan Nemeth - Administrative Assistant		TIME COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Bennette Pena and Daniel Konishi conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPAs met with and Sister Magdalene Grace, Care Coordinator and explained the purpose of the visit. There are currently (17) elderly residents 60 years and older residing in the facility. Facility is licensed to care for elderly residents age range 60 and over, 28 ambulatory, of which 28 may be non ambulatory, hospice waiver for 7. Shortly after, LPAs met with Miguel Angel Gonzalez, Maintenance Technician/Supervisor who assisted us with the Physical Plant tour. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed.  There is a visitor sign-in station located in the main entrance lobby. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Staff are adhering to infection control requirements. Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. Hospice Waiver for 7 is approved. A fire clearance is in place. Fire Drill was last conducted on 4/29/2024. Liability Insurance is in place and expires 06/15/2024. Physical Plant/Environment Safety: The facility is a 2-story building located in a residential community. The facility consists of: First floor: reception area, living room with covered fireplace, dining area, (10) resident bedrooms, administration office, break room, nurses/medication room, kitchen, storage room, laundry room, conference room and outdoor seating/patio areas. Second floor: (11) resident bedrooms, living room with covered fireplace, Food storage room, Electrical room, Break room, Housekeeping room, elevator/telephone/data room, and laundry room. Each bedroom has a smoke detector, bed, linen, dresser, light, chair and sufficient closet space. Bathroom has non-skid materials and contained hygiene supplies including liquid soap, paper towel and toilet paper. There is a fire place in the living room in each floor that is secured and fully covered. 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. Kitchen knives, sharps objects, cleaning supplies and toxic substances are locked and inaccessible to residents. There are (9) fire extinguishers observed in the entire facility that were fully charged and serviced on 05/09/2024. LPAs tested hot water temperature in seven (7) random resident rooms and measured within the required 105 - 120 degrees Fahrenheit. Water temperature readings are as follows: Room C1 - 114.6 deg F Room C2 - 114.2 deg F Room C6 - 115.8 deg F Room C7 - 115.3 deg F Room C9 - 114.0 deg F Room C21 - 115.1 deg F Room C28 - 115.1 deg F ***CONTINUED ON LIC809-C**

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GOOD SHEPHERD COTTAGE ASSISTED LIVING	FACILITY NUMBER: 198602600
	VISIT DATE: 05/31/2024

NARRATIVE

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Staffing: A total of twenty one (21) staff members including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. LPAs interviewed (4) staff.
Personnel Records/Staff Training: LPAs reviewed four (4) staff files and confirmed health screenings and fingerprint clearances. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Kathryn Klein/Sister Marie Estelle's Administrator certificate is valid and will expire on 12/23/2024.
Resident Rights-Information: Resident personal rights are posted. Notice of visiting policy is posted. Per staff, facility provides internet services to all residents and have access to the facility phone. LPAs interviewed (4) residents.
Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed.
Activities calendar is up to date and posted near the dining area. The facility has a Resident Council. Facility provides equipment and space to accommodate both outdoor and indoor activities.
Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Sanitation practices and kitchen cleanliness was observed. Kitchen staff workers were observed to be using disposable gloves while working.
Incidental Medical and Dental: Four (4) centrally stored resident medications were reviewed; containing 30-day supply of medications. Medical and dental transportation is provided.
Resident Records/Incident Reports: Resident files are maintained at the facility. A total of three (3) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, Medical consent, Medication records. RCFE complaint poster and Personal rights were observed posted in the 1st floor.
Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place. Records of resident Appraisal and Needs services plans are part of Emergency training.
Residents with Special Health Needs: Currently, one (1) resident receives hospice care and zero (0) bedridden residents.

No deficiencies cited. An exit interview was conducted, and a copy of this report was provided to Nathan Nemeth, Administrative Assistant.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

LIC809 (FAS) - (06/04)

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