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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602600
Report Date: 04/01/2025
Date Signed: 04/01/2025 12:18:10 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/27/2025 and conducted by Evaluator Erik Zaragoza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250327151212
FACILITY NAME:GOOD SHEPHERD COTTAGE ASSISTED LIVINGFACILITY NUMBER:
198602600
ADMINISTRATOR:KLIEN,KATHRYNFACILITY TYPE:
740
ADDRESS:1218 ROYAL OAKS DRTELEPHONE:
(626) 239-0710
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY:28CENSUS: 20DATE:
04/01/2025
UNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Nathan Nemethe - AdministratorTIME COMPLETED:
12:32 PM
ALLEGATION(S):
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Staff is refusing to accept resident back after hospital stay
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Erik Zaragoza conducted an initial unannounced complaint visit to investigate the allegation listed above. LPA met with Nathan Nemethe, administrator for the facility, and explained the purpose of the visit.

The investigation consisted of the following: LPA interviewed Staff #1 - 2 (S1 - S2), and also obtainted the Admissions Record, Admission's Agreement, most recent Physician's Report, most recent Appraisal, and also hospital records dated 3/27/2025 for Resident #1 (R1). LPA attempted to interview R1, however they are currently hospitalized at the time of the visit.

The investigation revealed the following: In regards to the allegation that "Staff is refusing to accept resident back after hospital stay," it is alleged that that following R1's hospitalization on 3/1/2025, they have not been accepted back into the facility due to the level of care R1 requires.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 28-AS-20250327151212
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/01/2025
NARRATIVE
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During interviews with the staff, none of them corroborated the allegation. One of the staff interviewed stated that since R1's hospitalization, the physician that has been attending to R1 at the hospital has determined that the resident is currently bedridden and requires total assistance with their Activities of Daily Living (ADLs), and the facility is not licensed to care for any bedridden residents. Another staff interviewed confirmed that R1 does require a higher level of care, and that the physician attending to R1 has stated that he requires care at a skilled nursing facility (SNF). The staff stated that if R1 recovers after rehabilitation at the SNF then they would be able to return to the facility. During record review, LPA confirmed that the facility does not have an approved fire clearance for any bedridden rooms. In reviewing the most recent physician's report for R1 dated 3/28/2025, it documents that R1 is ambulatory status is now "bedridden." Review of the hospital records for R1 dated 3/27/2025 also document that they require maximum assistance with their bed mobility, all transfers, and that their anticipated discharge disposition is a skilled nursing facility.

Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2